FIELD, B.C. – A train derailment that led to the death of three crew in 2019 has forced the Transportation Safety Board to recommend significant changes, including a change in Canadian Pacific Railway’s corporate safety culture.
The Transportation Safety Board (TSB) released its findings and three new recommendations on Thursday (March 31) following the three-year investigation into the Feb. 3 2019 derailment that killed Andrew Dockrell, Dylan Paradis and Daniel Waldenberger-Bulmer.
The board found safety deficiencies contributing to the accident included lack of experience and training, degradation of air brake systems in extreme cold temperatures of up to -28 C and failure to secure hand brakes.
Kathy Fox, TSB chair, said more needs to be done to make railway winter operations in steep mountain environments safer, including better brake testing, automatic hand brakes and a change in Canadian Pacific Railway’s corporate safety culture.
“The board is making three recommendations to address systemic safety risks found in this investigation,” she said during a press conference on Thursday (March 31).
According to the investigation that took three years to wrap up, the crew on a grain train descending the steep 13.5-mile-long (21.7 kms) Field Hill was not able to maintain the required speed of at or below the maximum 15-mph limit (24 kilometres per hour).
The crew had to apply the brakes in an emergency, bringing the train to a stop at 9:49 p.m on Feb. 3, 2019.
The brake cylinder pressure retaining valves were set on 84 cars to retain residual air pressure – which would allow the train to once again continue on its journey to Vancouver – 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, about 2.5 hours after the train had been stopped in the emergency, the temperature had dropped to −28 °C and the train’s air brake system had been leaking compressed air, which reduced the brakes’ capacity to hold the train on the steep grade.
Dan Holbrook, TSB’s manager of rail operations, said after the relief crew took over, the train began to creep forward and accelerate uncontrolled down the steep grade at 12:42 am on Feb. 4.
He said the train reached 53 mph (85 kmh).
“At this speed, the train was not able to negotiate the sharp 9.8-degree curve immediately before the Kicking Horse River bridge,” he said.
“Two locomotives and 99 cars derailed and the three relief crews members were fatally injured.”
The investigation found 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 after being stationary on the hill for around three 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 train master, they were not recognized as problematic, according to the findings.
In addition, 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.
Holbrook said applied airflow, as it is known to air brake experts, can be indicative of “brake system leakage, malfunction and the unintentional release of brakes on a train”.
“In this instance, the train master’s training and experience did not adequately prepare him to evaluate the circumstances or to make the decision he was tasked with,” he said during the press conference.
While the train had passed the required brake test in Calgary prior to departure, Holbrook said these tests have their limitations.
“They only show if the brakes will apply and release, but not how effective they are, particularly in cold ambient temperatures,” he said.
Based on the weight of the train, the track gradient and the stopping distance, the investigation determined that the brake effectiveness of the train during the emergency stop was in the 60 to 62 per cent range.
“After the train had been stationary for approximately three hours, the brake effort had further degraded to less than 40 per cent of the maximum and could no longer hold the train on the steep mountain grade,” said Holbrook.
“The main factors were the passage of time, the extreme cold temperatures and the leakage of brake cylinder pressure. As handbrakes had not been applied, once the leakages of brake cylinder pressure reached a critical threshold, the train began to move on its own.”
Coming out of the investigation, one of the TSB’s key recommendations centred on Canadian Pacific Railway’s safety management.
The TSB called on Transport Canada to require CP to demonstrate that its safety management system can effectively identify hazards, including employee hazard reports and data trends, assess the associated risks and implement mitigation measures and validate that they are effective.
Fox said safety hazard reports involving trains losing the ability to maintain speed descending the Field hill in cold weather had been submitted to CP by train crews for several years.
“Yet, year after year, the reports were closed, no risk assessment was conducted and insufficient corrective action was taken,” she said.
“On the day before the accident, the locomotive engineer who lost his life had descended Field hill on a grain train using maximum available braking,” she added.
“The safety hazard report he had prepared about the event was recovered from the accident site, but he never had the opportunity to submit it.”
Fox said CP’s overall corporate safety culture and safety management framework must incorporate a means to comprehensively identify hazards, including the review of safety reports and data trends analyses and assesses risks before making operational changes.
Until this happens, she said: “The effectiveness of CP’s safety management systems will not be fully realized.”
The TSB has also asked Transport Canada to require freight railways to develop and implement a schedule for the installation of automatic parking brakes on freight cars, with a priority put on retrofitting cars used in bulk commodity unit trains in the mountains.
Fox said unplanned and uncontrolled movements of railway rolling stock have been a concern for the TSB for some time now.
She said there were, in fact, 589 such events from 2010-19 reported to the TSB, adding these are “high risk events that can have catastrophic consequences”.
“The TSB remains concerned that the current defences are not sufficient to reduce the number of uncontrolled movements and improve safety and this is why it was added to the TSB watchlist in 2020,” she said.
Fox said new technology for enhancing train brake performance is available to North American railway companies, including automatic parking brakes, which have been tested and approved for use, but have not been widely adopted.
“Automatic parking brakes mechanically lock the brakes in the applied position on each rail car when brake pipe pressure is depleted, as occurs during an emergency brake application,” she said, noting they are not affected by brake cylinder leakage.
“Until physical defences such as automatic parking brakes are implemented across the Canadian railway network, the risk of uncontrolled movements due to inadequate train securement will persist, especially on steep grades.”
Fox said TSB believes the safety and operational benefits far outweigh the costs of implementation of automatic parking brakes.
“This technology is available and it’s available now,” she said.
Lastly, the TSB recommends Transport Canada 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.
In the case of the Field derailment, Fox said the brake cylinders on the freight cars were leaking compressed air, a situation that was made worse by their age and condition as well as the extreme cold temperature.
She said these factors reduce the capacity of the train’s air brake system to control train speed and subsequently to hold the train stationary on the descending grade.
“To reduce the risk that freight cars will develop excessive air leakage from brake cylinders, it is crucial that they undergo regular testing and maintenance, however, there are no specific industry or regulatory requirements for regular maintenance on freight car brake cylinders,” said Fox.
“Over the years, the industry’s approach to brake cylinder maintenance has become one of opportunity-based preventative maintenance, however without periodic scheduled maintenance, brake cylinder leakages can jeopardize safe train operations when sustained brake applications are required, especially on steep grades in cold weather conditions.”
Holbrook said critical factors were not factored in after the inbound crew had to make the emergency stop and before resuming with the relief crew, including putting on hand brakes.
He said the train had experienced a loss of control. “ Yet a decision was taken to resume operation of this train without exploring why…” he said,
“Things that should have happened, didn't happen.”
Canadian Pacific Railway issued a statement on Thursday afternoon after the TSB shared the findings of its three-year investigation earlier in the day contesting many of the investigation’s findings and maintaining the crews were well trained.
The railway giant said it continues to mourn the loss of Paradis, Dockrell and Waldenberger-Bulmer.
“Given the gravity of this incident and the tragic loss of life, it was extremely disappointing that the TSB misrepresented the facts at today’s news conference and misunderstood key facts about the incident in its report,” according to the statement.
The company said the assessment of the situation and the decision to apply brake retainers were made using the collective knowledge and experience of everyone involved.
“Both the locomotive engineers of the inbound crew and the relief crew were fully-trained, qualified and certified, and were well-experienced in the handling of trains on mountain grades,” according to the statement.
“The train master was also a qualified locomotive engineer with experience on mountain grades. Both crews and train master agreed on the appropriate steps to be taken in line with existing procedure.”
According to CP’s statement, the Field Hill operating procedure itself was based on operating practices established in collaboration with the running trades employees, Transport Canada and company management in the wake of previous incidents more than two decades ago.
“This was not an issue of training and/or experience,” the statement reads.
CP also disagrees with the TSB’s findings on brakes.
The company said the board “erroneously concluded, based on inappropriate extrapolation of data and unsupported inferences”, that train exhibited poor braking performance.
“As confirmed in the report, the train involved in the incident was fully functional, met all industry standards and passed all regulatory brake test inspections,” according to the statement.
CP maintains it demonstrated that its safety management system contains all of the necessary elements as required by regulations.
“CP’s safety hazard reporting procedure was effective, both in form and in execution,” says the statement. “There were no systemic hazards that were not appropriately addressed, including Field Hill train braking performance, by CP’s safety management system.”
The railway giant maintains it has a strong culture of safety and always works to improve.
“CP will be addressing the inaccuracies and misrepresentations made at today’s news conference and in the report in greater detail directly with the TSB,” according to the statement.
The RCMP investigation into the derailment is ongoing.
