Rail transportation safety investigation R19C0015

Update April 2019

Given the potential consequences of an uncontrolled train movement, the TSB issued two rail safety advisory letters on 11 April 2019.

  • 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.

This investigation is in the report phase. The update below replaces the previous update published on 5 February 2019.

Table of contents

Main-track derailment

The occurrence

On 4 February 2019, Canadian Pacific train 301-349 was proceeding westward to Vancouver when 99 cars and 2 locomotives derailed at Mile 130.6 of the 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.

Circumstances

  • The train was a (distributed power) unit grain train composed of 112 covered hopper cars and 3 locomotives.
  • The 3 locomotives were positioned at the front, middle and tail-end of the train.
  • Following the derailment, only 13 cars and the tail end locomotive remained on the track.
  • The lead locomotive and some of the cars derailed on a curve 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 an embankment.
  • The remaining cars, including the mid-train remote locomotive piled up behind.
  • The accident took place between the Upper Spiral Tunnel and the Lower Spiral Tunnel near Field, B.C.
  • The tail-end locomotive and 10 cars (4 of which did not derail) came to a stop at the west portal in the Upper Spiral Tunnel.
  • The other 9 cars that did not derail were close to the middle of the train.
  • At some point before the head-end came to a stop at Mile 130.6 the train had come apart between the mid-train and tail-end locomotives.

What we know

The investigation team has established the following facts based on its information-gathering work:

  • A loss of control of the train occurred.
  • The train had been stopped with the air brakes applied in emergency at Partridge, the last station prior to the entrance to the Upper Spiral Tunnel.
  • A change of crews had occurred at this location as the previous crew were closing in on their maximum hours of service.
  • The occurrence crew had just arrived and boarded the train, but were not yet ready to depart.
  • The train, which had been stopped on the grade with the air brakes in emergency for about 3 hours, began to move on its own.
  • There were no hand brakes applied on the train. The train accelerated beyond the maximum track speed set at 20 mph given the tight curves and steep mountain grade, and the train derailed. 
  • Locomotive event recorder data from the lead locomotive could not be retrieved as the event recorder and the lead locomotive were severely damaged in the derailment. 
  • Locomotive event recorder data was recovered from the tail-end remote locomotive and from the mid-train remote locomotive.  

Progress to date

On site, the team has completed the following:

  • collect data from the accident site
  • collect electronic data from the locomotives
  • conduct interviews
  • examine and photograph the wreckage
  • identify components for further examination by the TSB Engineering Laboratory

Next steps

The investigation team has been augmented by investigators from the TSB Engineering Laboratory and the TSB Human Factors Division. The next steps will include the examination of:

  • weather conditions and the railway's winter operating plan
  • train operations specific to the Field Hill
  • operational policies for mountain grade train operations
  • railway training specific to the reliability of air brakes in extreme cold temperatures
  • maintenance history of the rolling stock
  • regulatory requirements

The TSB's investigation will determine causes and contributing factors of this accident. Concurrent investigations are being conducted by other agencies and for other purposes. The TSB will work with these agencies to ensure that those affected, including the next of kin, are provided with information about the accident and the next steps.


Safety communications

2019-04-11

Rail Safety Advisory 617-04/19: Prevention of uncontrolled train movements for trains stopped in emergency on grades of less than 1.8%

2019-04-11

Rail Safety Advisory 617-05/19: Air brake system inspection and maintenance on grain hopper cars used in CP unit train operation


Media materials

News releases

2019-04-18

Investigation update notice: Train derailment near Field, BC
Read the news release

2019-02-05

Investigation update notice: Train derailment near Field, BC
Read the news release

Media advisory

2019-02-04

TSB will provide a news briefing on its investigation into the train derailment that occurred near Field, British Columbia
Read the media advisory

Deployment notice

2019-02-04

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.


Investigation information

Map showing the location of the occurrence


Investigator-in-charge

Photo of Don Crawford

Don Crawford has many years of national and international railway experience. Early in his career, he was a locomotive engineer with Canadian National (CN) on its British Columbia North corridor and in Vancouver-based territories, and with BC Rail. Later, Don was a staff member at CN’s Gimli, Manitoba, training facility. He also worked in Kosovo after the 1998–99 war as part of the United Nations peacekeeping effort to help restore rail service to the country, and was a locomotive engineer instructor in Saudi Arabia. Since joining the TSB, Don has earned a Bachelor of Science degree in railway operations management from Glasgow Caledonian University and obtained certification as a Canadian Registered Safety Professional


Photos

  Download high-resolution photos from the TSB Flickr page.

Class of investigation

This is a class 2 investigation. These investigations are particularly 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

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. 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.
  3. 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.

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