Rail transportation safety investigation R19C0015
Updated 1 February 2021
Update of the current status of the investigation. This investigation is in the report phase.
On 4 February 2019, shortly after a crew change, Canadian Pacific Railway (CP) train 301-349 that was proceeding westward to Vancouver, British Columbia, began to roll uncontrolled, resulting in the derailment of 99 cars and 2 locomotives at Mile 130.6 of the CP Laggan Subdivision, near Field, British Columbia (B.C.). The train crew consisted of a locomotive engineer, a conductor, and a conductor trainee. The 3 crew members were fatally injured.
The train was a distributed power, unit grain train comprised of 112 covered hopper cars and three locomotives. The three locomotives were positioned at the front, middle, and tail end of the train. While rolling uncontrolled down the hill between the Upper Spiral Tunnel and the Lower Spiral Tunnel the train separated into three sections and derailed.
The first section which included the lead locomotive and the first 35 grain cars derailed on a curve immediately prior to a bridge. The lead locomotive came to rest on its side in the Kicking Horse River. A number of derailed cars came to rest on the river bank. The middle portion of the train was comprised of 40 grain cars and the mid-train remotely controlled locomotive. Most of these cars came to rest derailed on their sides or in a pile-up. The mid-train remotely controlled locomotive derailed upright. Eight grain cars from this section of the train did not derail.
The separated rear portion of the train came to a rest partially inside the west portal of the Upper Spiral Tunnel. Inside the tunnel, two grain cars derailed upright, one grain car derailed the rear truck only and remained upright, and four grain cars remained on the track. Outside the tunnel, seven grain cars derailed on their sides and 15 grain cars derailed in a pile-up down the embankment. The tail-end remote locomotive remained on the track.
Following the derailment, 13 grain cars and the tail-end locomotive were recovered for further examination and testing.
Investigation status as of 1 February 2021
The investigation is in the report phase, the final phase of a TSB investigation. The draft report will be circulated to designated reviewers on a confidential basis for comment. For more information, please refer to the TSB investigation process.
Safety communications to date
The TSB issued the following three Rail Safety Advisory (RSA) letters—two on 11 April 2019 and a third on 17 April 2020:
- RSA 04/19 advises Transport Canada to ensure that effective safety procedures are applied to all trains stopped in emergency on both “heavy grades” and “mountain grades”.
- RSA 05/19 advises Transport Canada to review the efficacy of air brake system inspection and maintenance procedures for grain hopper cars used in unit train operations, and ensure that these cars can be operated safely at all times.
- RSA 04/20 advises Transport Canada that an alternate approach to determining the effectiveness of freight car air brakes is required to ensure that departing trains have sufficient effective brakes to operate safely.
In addition to the RSA letters, the Minister of Transport issued Ministerial Order 19-03 under the Railway Safety Act on 8 February 2019 that required the railway companies to apply hand brakes on trains stopped in emergency on grades of 1.8% (i.e., mountain grade) or greater.
Furthermore, on 28 April 2020, Transport Canada approved the railway industry’s proposed new Rule 66 of the Canadian Rail Operating Rules which outlined the minimum hand brake application requirements for securing attended trains on heavy or mountain grades.
In an effort to monitor the implementation of and compliance with Rule 66 by railway companies, Transport Canada also issued a Ministerial Order (MO 20-08) on 27 April 2020 that requires railway companies to report all occurrences of emergency stops on heavy or mountain grade. The reporting began on 1 July 2020 and will last for 12 months until 1 July 2021.
The investigation team has completed the Field Phase and the Examination and Analysis Phase.
- Examined and collected all relevant data from the accident site
- Examined and photographed the wreckage
- Identified components for further examination by the TSB Engineering Laboratory
- Collected electronic data from the locomotives
- Collected communications with the train crews:
- radio communications with the rail traffic controller (RTC)
- telephone transcripts
- Conducted interviews
- Weather conditions
- Inspection and maintenance records for railcars and locomotives on occurrence train
- Train handling and train performance
- Field Hill train operations
- Railway's winter operating plan
- Operational policies for mountain grade train operations
- Employee and supervisor training, qualification, and operational experience relevant to:
- Field Hill operations
- freight train air brake system operation
- extreme cold temperature operations
- train securement policies
- Performed cold-weather and shop testing on 13 grain hopper cars recovered from site:
- Air brake performance
- Brake cylinder leakage
- Automated Single Car Test (ASCT)
- Hand brake efficiency
- Reviewed and analyzed:
- Historic and current operations on the Field Hill
- Mechanical condition and effectiveness of the air brakes on the grain hopper cars recovered from the site
- Inspection and maintenance practices on the grain hopper fleet
- National Research Council (NRC) report on Automated Train Brake Effectiveness (ATBE) Test Technology Demonstration and Assessment
- Operational oversight:
- railway management
- occupational health and safety
- Organizational culture and safety culture
- Human factors and performance:
- decision making
- crew resource management
What we know
The investigation team has established the following facts based on its information-gathering work:
- The train stopped with the air brakes applied in emergency at Partridge, the last station prior to the entrance of the Upper Spiral Tunnel.
- After a job briefing between the initial train crew and a supervisor, the train conductor applied retainer valves to the high-pressure position on 84 grain cars, or 75% of the cars on the stationary train.
- There were no hand brakes applied on the train.
- A change in train crew at this location was ordered because the previous crew were approaching their maximum hours of service.
- The relief crew had just arrived and boarded the train, but were not yet ready to depart, when the train began to move on its own.
- The train had been stopped on the grade with the air brakes applied in emergency for about 3 hours when a loss of control occurred.
- The train accelerated beyond the authorized maximum track speed of 15 mph to a speed in excess of 51 mph, and it derailed.
- The data from the locomotive event recorder on the lead locomotive could not be retrieved because the data recorder and the locomotive were severely damaged in the derailment.
- Data were recovered from the locomotive event recorders on the mid-train and tail-end remote locomotives.
Once ready, the draft report will be circulated to designated reviewers for comments on a confidential basis, to ensure factual and technical accuracy. The comments submitted will be considered during the preparation of the final report.
TSB will provide a news briefing on its investigation into the train derailment that occurred near Field, British Columbia
Read the media advisory
TSB deploys a team of investigators to the site of a train derailment near Field, British Columbia
Calgary, Alberta, 4 February 2019 – The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the site of a Canadian Pacific train derailment near Field, British Columbia. The TSB will gather information and assess the occurrence.
TSB statement concerning CBC report related to TSB investigator comments about the Canadian Pacific freight train accident near Field, BC, in February 2019
Read the statement
Map showing the location of the occurrence
Peter Hickli has been with the Transportation Safety Board of Canada (TSB) since 2006. He holds the position of Senior Regional Investigator, Rail/Pipeline, in Vancouver, British Columbia.
During his time at the TSB, Mr. Hickli has been the investigator-in-charge (IIC) of 13 rail accident investigations, including a Class 2 investigation (R17V0096), and provided technical expertise on many others, including the Lac-Mégantic investigation (R13D0054).
Before joining the TSB, Mr. Hickli worked for BC Rail and Canadian National (CN) for 30 years. During that period, he served a four-year Carman apprenticeship and worked extensively in the mechanical departments at BC Rail and CN, both as a unionized employee and as a manager.
In the course of his career, Mr. Hickli has served as a member of derailment investigation teams and hazardous materials teams, as a hazardous materials technician and as an advanced tank car specialist.
Download high-resolution photos from the TSB Flickr page.
Class of investigation
This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
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.