The Transportation Safety Board is unveiling its final investigation report into the train derailment that occurred in Field near the B.C., Alberta border in 2019, that left three men dead.
TSB is issuing three recommendations, with a specific focus on calling for enhanced standards in cold temperatures and mountainous conditions.
The effectiveness of the No. 1 brake test, which is conducted on trains to ensure they are up to safety regulations to operate, was called into question by the TSB in April 2020.
The brakes system had been leaking cylinder pressure while it was delayed on a steep grade, causing it to creep forward before accelerating uncontrollably along the tracks at high speed, and was not able to negotiate the steep curve causing the train to derail.
The TSB report revealed that the No. 1 brake test only shows if the brakes will apply and release, said panellist Dan Holbrook, Manager, Head Office and Western Regional Operations, not how effective they are in cold temperatures.
Based on the weight of the rain and the stopping distance, the effectiveness of the brake on the train in question was in the 60-62 per cent effectiveness range.
The brake had further degraded to 40 per cent due to the amount of time it was applied for. The cold, which was approximately -20 C at the time of the incident, and leakage of cylinder pressure, were responsible for the degradation according to Holbrook. Hand brakes had not been applied, which allowed the train to move on its own, where it accelerated uncontrollably, resulting in the derailment.
Increased demand for air from the locomotives was observed after the brakes had been applied, which can be an indicator of brake system leakage and malfunction. This was discussed with the trainmaster after an emergency stop and was not deemed problematic. The trainmaster’s training and experience did not prepare him for the event, Holbrook found.
The TSB did not make a recommendation on training and employee standards, as the board had previously issued a recommendation in 2018 after a 2016 investigation into an accident that occurred in Ontario.
The first of the TSB’s three recommendations as outlined by Kathy Fox, TSB chair, was focused on testing and time-based maintenance for cylinder brakes.
Leaking of compressed air is made worse by age, conditions and extreme cold, which reduces the capacity to control train speed and to hold the train stationary on the steep descending grade such as that of Field Hill.
To reduce this risk, the cylinder brakes must undergo regular testing and maintenance said Fox, but there are no industry requirements for this.
“Over the years the industry’s approach is one of opportunity-based preventative maintenance,” said Fox.
Without periodic maintenance, leakage can jeopardize safety on steep grades in cold weather conditions.
The TSB recommends Transport Canada establish and enhance test standards and time-based maintenance for cars operating on steep grades and in cold.
The second recommendation was the implementation of automatic brakes.
“Unplanned and uncontrolled movements have been a concern for the TSB for some time,” said Fox.
Automatic parking brakes mechanically lock the brake and are not affected by leakage. Automatic brakes can hold a train on a steep grade indefinitely, while reducing crew workload, explained Fox. Despite this, they have not been widely adopted.
“Until these are implemented across the rail network, the risk of uncontrolled movement will persist, especially on steep grades,” said Fox.
“Therefore the board recommends Transport Canada require Canadian railways develop a schedule for the installation of these brakes on cars and prioritizing the retrofitting of cars used in mountain grade territory. ”
The third recommendation calls into question the culture of safety management and risk assessment at CP Rail.
“Safety hazard reports involving braking unit grade trains on Field Hill have been submitted to CP Rail for several years, yet year after year, no risk assessment was conducted and insufficient correction taken,” said Fox.
“It’s obvious more must be done to reduce risk to employees, public and the preventable loss of life.”
The board recommends Transport Canada require CP to demonstrate its safety management system identity hazards using all information including employee hazard reports and data trends to implement and validate effectiveness.
Years of reports of safety issues at Field Hill failed to be elevated to supervisors and risk assessments were not conducted in order to improve safety, according to Fox.
She highlighted this by stating that the engineer who lost his life descended the hill the day before he lost his life and a safety hazard was recovered from the site, which he never had the opportunity to submit.
CP Rail refuted the findings by the TSB in a statement Thursday afternoon, saying the regulator “misrepresented the facts.”
The company said that the relief crew, original crew and trainmaster collectively agreed on the appropriate steps to be taken in line with existing procedure.
“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,” CP said. The report also called into question industry standards, which was outlined in both the first and second recommendations.
CP also denied the failure of the brakes.
The Ministry of Transportation has 90 days to respond on how they will implement the recommendations, which TSB will
The Ministry of Transportation has 90 days to respond on how they will implement the recommendations, which TSB will then rate and will continue to follow up to ensure they are executed.