Canadian Railroads > 1997 Field Hill runaway also involved Emergency Brake application

On December 2, 1997,
CP lost an 84 car loaded grain train on the Field Hill.
Thankfully, there was no loss of life.
It was also a cold day of minus 13 Celsius.
Due to train handling issues, the train also stopped at Partridge in emergency.
Neither retainers nor hand brakes were applied,
rather a decision was made to recharge the air brake system while proceeding.
A depleted air brake system was cited as a factor in the runaway accident,
There was an issue with Dynamic Brake recovery procedures on the new GE AC4400 locomotives.
Fatigue was cited as well.  
The locomotive engineer had only 2.5 hours rest in the 29 hours preceding the accident.

Subsequent to the runaway on December 2, 1997,
CP issued Operating Bulletin No. 188 on December 5, 1997.

Applying to a train "standing on a grade which is greater than 1.5%",
after a "second emergency brake application on that grade"
where "locomotive brakes are not sufficient to prevent train movement."
The new instruction was to "NOT" attempt emergency brake application recovery
until retaining valves were set to high pressure position on 50 percent of loaded cars,
"OR" hand brakes were applied to 50 percent of cars.
If used, hand brakes were not to be released until the air brake system was fully recharged.

And this caveat,
"NOTE: This does not alter the requirement to apply hand brakes or retainers when conditions
are such that their use is considered necessary after one emergency."

The entire report,

http://www.bst-tsb.gc.ca/eng/rapports-reports/rail/1997/r97c0147/r97c0147.pdf

 

I am sure the taught of setting 40 handbrakes on that train crosssed the debarking crew...... obviously right but unrealistic bulletin in day to day ops practice or attitude