Release of investigation report R19C0015 – Yoho
Speaking Notes - R19C0015 (Yoho)
Check against delivery.
On February 4, 2019, a Canadian Pacific Railway unit grain train, hauling 112 loaded hopper cars, derailed while descending uncontrolled on a steep mountain grade near Field, British Columbia, fatally injuring three crew members. [pause] Our thoughts and condolences continue to be with those who lost their loved ones in this accident.
Today, in addition to explaining what happened and why, the Transportation Safety Board of Canada is issuing 3 recommendations, aimed at making cold-weather train operations safer through mountainous rail territory.
Specifically, we are calling for:
- enhanced test standards and time-based maintenance for brake cylinders on freight cars operating on steep descending grades in cold ambient temperatures;
- installation of automatic parking brakes on freight cars, prioritizing those used in bulk commodity unit trains on mountain-grade territory; and
- Canadian Pacific Railway Company to demonstrate to Transport Canada that it can effectively identify hazards and assess and mitigate risks using all available information.
I would like to remind Canadians that, in accordance with our enabling legislation, the sole purpose of the TSB is to advance transportation safety—by conducting independent investigations, determining causes and contributing factors, identifying safety deficiencies, and making recommendations to reduce them. We do not assign fault or determine civil or criminal liability.
Dan Holbrook will outline what happened on the day of the accident and detail what our investigation uncovered.
Thank you, Kathy.
On February 3rd, 2019 at approximately 2:30 pm local time, CP train 301 departed Calgary, Alberta, westbound towards Field, British Columbia, en route to Vancouver. This route is part of CP's main corridor to the west coast, traversing mountains characterized by steep grades and sharp curves. Before leaving Calgary the train underwent and passed the required air brake test.
The train was operating in extreme cold temperatures below minus 25 degrees Celsius. Around 9:30 PM, the train started the 13.5-mile descent down Field Hill. When the entire train entered onto the steepest part of the grade, it was not able to hold its speed at or below the 15-mph speed limit. When the speed reached 21 mph, the crew applied the brakes in emergency, as required by railway operating procedures. The train came to a stop at Partridge at around 9:50 PM, with about 9 miles of mountain grade remaining before Field.
After the train was brought to a stop, the decision was made to set brake cylinder pressure retaining valves on 84 of the 112 cars only, rather than retaining valves and hand brakes. This would facilitate getting the train underway by releasing the brakes and allowing the train’s air brake system to recharge as the train continued its descent—an operation called “release and catch.” Since the inbound crew had reached the end of their shift, a relief crew was called in to take over control of the train and complete the trip to Field.
The relief crew consisted of a locomotive engineer, a conductor and a conductor trainee. By the time they arrived at Yoho—the closest road access point to the train—at around 10:45 PM, the temperature was minus 28 degrees. From there, they were transported to the train, about 2.5 miles east, using an on-track vehicle; but delays, including a frozen track switch, meant they did not arrive at the train until 12:20 AM. All the while, the train’s air brake system had been leaking brake cylinder pressure, reducing its capacity to keep the train stopped on the grade.
The relief crew took over and were preparing to resume the trip when the train began to creep forward at around 12:42 AM. The train gradually accelerated uncontrolled down the steep mountain grade, reaching 53 mph, a speed well in excess of the maximum authorized speed for this section of track. At this speed, the train was not able to negotiate the sharp 9.8-degree curve immediately before the Kicking Horse River bridge. Two locomotives and 99 cars derailed, and the 3 relief crew members were fatally injured.
Now I’ll turn to the main findings in our investigation.
The investigation found that several factors contributed to the train’s degraded braking performance. While the train had passed the required brake test in Calgary prior to departure, 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.
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% range.
After the train had been stationary on Field Hill for approximately 3 hours, the brake effort had further degraded to less than 40% of the maximum and could no longer hold the train on the steep mountain grade. The main factors were the passage of time, the extreme cold temperatures, and the leakage of brake cylinder pressure. Since hand brakes had not been applied, once the leakage of brake cylinder pressure reached a critical threshold, the train began to move on its own.
The investigation also determined that earlier in the trip from Calgary, and just prior to the emergency stop, an increased demand for air from the locomotives had been observed after the brakes were applied. Applied air flow, as this is known to air brake experts, can be an indicator of air brake system leakage, malfunction, and the unintentional release of brakes on a train. Although this observation was discussed with the trainmaster during a job briefing after the emergency stop, it was not recognized as problematic.
In order to prepare the train for getting underway again, and because the situation was the first emergency stop, critical factors such as ambient temperature, brake system performance, and the significance of the applied air flow events were not considered, and only retainers were applied rather than retainers and hand brakes. In this instance, the trainmaster’s training and experience did not adequately prepare him to evaluate the circumstances, or for the decision he was tasked with making.
TSB Chair Kathy Fox, will now walk us through what needs to be done to make winter operations on mountain grades safer.
Thank you, Dan.
Following this accident, and while the TSB investigation was still underway, safety actions were taken by both Transport Canada and Canadian Pacific Railway Company.
Transport Canada introduced several initiatives, one of which was to issue a Ministerial Order requiring that trains stopped by an emergency brake application on a grade of 1.8% or greater immediately apply a sufficient number of hand brakes before recharging the air brake system. This Ministerial Order was superseded when the hand brake requirement was incorporated into the Canadian Rail Operating Rules as Rule 66.
For its part, CP
- revised the train handling procedures for the Laggan Subdivision with respect to the use of retainers and hand brakes before recovering from an emergency brake application on mountain grades; and
- monitored wheel temperatures on all westbound grain trains passing by detectors installed on the Laggan and the Mountain subdivisions. This resulted in more than 5000 grain cars being removed from service for repair.
However, more needs to be done. Specifically, the Board is making three recommendations to address systemic safety risks found in this investigation.
Recommendation – Time-based standards for brake cylinders
The first focuses on testing and time-based maintenance standards for brake cylinders. In this occurrence, the brake cylinders on the freight cars were leaking compressed air, a situation made worse by their age and condition and the extreme cold temperature. These factors reduced 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. 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 leakage can jeopardize safe train operations when sustained brake applications are required, especially on steep grades in cold weather conditions.
Therefore, the Board recommends that 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.
Recommendation – Automatic parking brakes
Moving to our second recommendation. [pause]
Unplanned and uncontrolled movements of railway rolling stock have been of concern to the TSB for some time now. In fact, there were 589 such events from 2010 to 2019 reported to the TSB. Our Lac-Mégantic investigation clearly illustrated that 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. This is why it was added to the TSB Watchlist in 2020.
New technologies for enhancing train brake performance are available to North American railways now. One of these is 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. Automatic parking brakes are not affected by brake cylinder leakage and so can hold a train on a steep grade indefinitely. They also reduce crew workload because crews no longer have to apply hand brakes manually on each car.
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, where the effectiveness of hand brakes cannot be tested. Therefore, the Board recommends that Transport Canada 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.
Recommendation – CP safety management
The third recommendation we are issuing today is about CP’s safety management.
Transport Canada’s Railway Safety Management Systems Regulations require railway companies to conduct risk assessments, especially when a safety concern is identified. To do so, railway companies are required to continually analyze their operations, current or emerging trends, and any recurring situations.
Safety management is also a key safety issue on the TSB Watchlist.
Safety hazard reports involving poor braking unit grain trains descending 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. 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. The safety hazard report he had prepared about the event was recovered from the accident site.
Until CP’s overall corporate safety culture and safety management framework incorporates a means to comprehensively identify hazards, including the review of safety reports and data trend analyses, and assesses risks before making operational changes, the effectiveness of CP’s safety management system will not be fully realized.
Therefore, the Board recommends that Transport Canada require Canadian Pacific Railway Company 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.
This tragic accident that took place on Field Hill demonstrates, once again, that uncontrolled movements of rolling stock continue to pose a significant safety risk to railway operations in Canada. 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.