Canadian Railroads > Field tragedy Update: New details revealed

The Transportation Safety Board released an update on its investigation of the runaway tragedy
that occurred near Field, B.C., on February 4, 2019,
including additional details of the time line of the runaway derailment. 

CP train 301-349 “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."

The original crew had started down the Field Hill,
but "had not been able to keep the train at (or under) the maximum authorized speed of 15 mph
using a progressive application of the air brakes and dynamic brakes.
When the speed reached approximately 23 mph, and despite the heavy (> 20 psi) application of the air brakes
in combination with full dynamic brakes, the locomotive engineer applied the air brakes in emergency.” 

The train came to a stop at Partridge at about 21:48.
The temperature was -28 C.
The grade at the location was 2.2 percent. 

“Subsequent to stopping, the crew performed the required job briefing with a supervisor
and the decision was made to set retainer valves
to the high-pressure position on 75% of the cars on the train (84 cars).
No hand brakes were applied.
After an extended period of about 2 hours 45 minutes, a relief crew arrived to replace the crew at Partridge,
whose maximum hours of service had been reached.
About 10 minutes later, the train began to move on its own.
The relief crew had not yet recovered the air brake pressure from the emergency brake application.
The crew members were in the process of securing the train
to facilitate the safe release and recharge of the air brakes.” 

"The accident took place between the Upper Spiral Tunnel and the Lower Spiral Tunnel near Field, B.C."

"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."

"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."

The relief crew, consisting of three CP employees, lost their lives in the accident.

http://www.tsb.gc.ca/eng/enquetes-investigations/rail/2019/r19c0015/r19c0015.html

http://www.tsb.gc.ca/eng/securite-safety/rail/2019/r19c0015/r19c0015-617-04-19-20190411.html

http://www.tsb.gc.ca/eng/securite-safety/rail/2019/r19c0015/r19c0015-617-05-19-20190411.html



Edited 1 time(s). Last edit at 04/18/19 11:29 by Marcus.

The supervisor was not trained on the proper operation of the airbrakes and I am not sure the 1st crew was either. Setting retainers once the train was in emergency would do no good to hold the brake set. All the air from the train line and brake cylinders on the cars would have been exhausted and as long the the brake valve on the engine was still in the emergency position the train would not recharge.  These reports do not indicate that .

The 2nd crew was set up by the failures occurring in the train before they boarded it. Running 3 units 12,000 hp on a 112 car 16,000 ton train was not near enough dynamic brakes even with the AC unit providing more dynamic retardation than a DC unit this train was under powered. We used to figure with DC units 1 hp per ton on a 1%grade so my guess on a 2.2 % grade you would have needs 5 units plus the use of airbrakes to handle the train safely down the grade and maybe they got away with this configuration in warmer weather but the cold temperatures play havoc with air brake systems and also cycle braking the train with insufficient dynamic brakes could lead to “pissing the air away trying to control the train speed. On Soda Ash trains in the UP Blue Mountains these trains would run 2x2x2 or 3x2x1. 

I have to agree with the previous reply by cctgm.

The incoming crew were following timetable special instructions when they placed the air brakes in emergency at Partridge when the 20 psi service application and the dynamic brakes failed to control the trains speed.

I worked the territory west of Field as an engineer, which also includes some serious grades and has the same instructions regarding train handling down steep grades.

Why weren’t the incoming crew instructed to secure hand brakes in sufficient number to hold the train as the first priority? Once satisfied that the train wasn’t going to move, the crew could then release the air brakes and fully charge the reservoirs, and set the retainers.

What is shocking is that a supervisor would instruct the incoming crew otherwise.

Similarly, given that the relief crew were relieving the crew of a train with an emergency brake application still in effect, why weren’t they instructed to secure handbrakes before doing anything else?

I’m still wondering what mechanical issues had previously delayed this train en route from Calgary so that the incoming crew ran out of time on a run which usually took about eight hours.

If the severe cold was causing air brake problems, the air brake rules allow for reducing the size of the train until the last car on the train is capable of a proper service brake application. Back in the days of caboose operation, conductors monitored the rear brake pipe pressure and if in their judgement there was insufficient pressure on the tail end, they would reduce the size of the train before decending Field Hill.

Posted from iPhone



Edited 3 time(s). Last edit at 04/19/19 09:05 by eminence_grise.

eminence_grise Wrote:
-------------------------------------------------------

> Why weren’t the incoming crew instructed to
> secure hand brakes in sufficient number to hold
> the train as the first priority?

Shouldn't that be second nature? Why would a crew need to be told to tie down the train after bigholing it on a mountain grade?


> What is shocking is that a supervisor would
> instruct the incoming crew otherwise.

In the 21st Century, not exactly shocking, unfortunately.

>
> Similarly, given that the relief crew were
> relieving the crew of a train with an emergency
> brake application still in effect, why weren’t
> they instructed to secure handbrakes before doing
> anything else?

Once again, inherit a train with no air in the trainline and not tied down, tie the train down should be the first thought.

TAW

A couple of questions and comments:
What were the qualifications of the "supervisor"?  The supervisor in that position should be required to have several years prior experience as an engineer in mountain territory.  This is the same requirement that the FRA has for RFEs or MOPs in the US.  A business degree won't do any good.

In defense of the Railroad, this has apparently only happened once before, on the UP in Gillette, Wyoming in 1999 when a coal train ran off an hour after breaking a knuckle in extremely cold weather.  I wouldn't have known about it except for reading an old NTSB report.

Not the point, handbrakes should have been applied as soon as the train stopped, period. A penalty labor payment should not have interfered with applying handbrakes, even if the crew was tired.

Lastly, train length doesn't really apply to a 1X1X1 DPU configuration such as this.  As each locomotive has an operating brake valve, the longest brake pipe in this 112 car train is  28 cars!
G 

I’m assuming the supervisor was based in the rail traffic office in Calgary.

A resource CP crews have in the Calgary office is the “diesel doctor”, a person with a knowledge of locomotives and possible faults and solutions. He is usually a shop mechanic or foreman with a good knowledge of the topic, and the job has proven its worth many times when crews on the road have been able to fix problems on his advice. Sometimes he reads from manuals and helps enterpret them. He is not however a rules or operating practice supervisor.

There are two classifications of company officers who travel on the trains to supervise and instruct. The titles may have changed in the years since I retired. A road manager (road foreman of engines) oversees the train and engine crews and usually is a very experienced engine service person on the territory. A diesel inspector is a field supervisor with a thorough knowledge of locomotives and rolling stock, and is a journeyman carman or locomotive shop man.

In the past, both types of supervisor would be sent to assist with a train with operating problems, and had the authority to instruct crews on troubleshooting and frequently would assist the crew to get the train over the road.

I’ve heard that the train had been experiencing mechanical problems causing delay earlier in the trip.

Were there no operating officers available to assist or have those positions been eliminated by the previous CEO?

Other supervisors based in the traffic control centre are chief rail traffic controllers and various corridor or commodity managers, not people with a knowledge of equipment operations

Posted from iPhone



Edited 1 time(s). Last edit at 04/19/19 14:37 by eminence_grise.

Does the report not address who decided/ordered that no handbrakes be tied and their reasoning why?



Edited 1 time(s). Last edit at 04/20/19 02:08 by darkcloud.

darkcloud Wrote:
-------------------------------------------------------
> Does the report not address who decided/ordered
> that no handbrakes be tied and their reasoning
> why?

The timetable special instructions for this portion of track require that a crew that has to control the speed of the train by placing the brakes in emergency immediately contact a supervisor and perform a job briefing . Those same printed instructions also describe what actions must be taken following such an event by the crew involved.

All radio communications between trains and the traffic control centre are recorded and I’m sure have been thoroughly transcribed and interpreted.

Also, each locomotive has an event recorder.

What was said in the radio job briefing may be the key to discovering why this event occurred.

Canada’s privacy laws differ from those in the US in regard to legal proceedings and which personal details can be made public. This is evident when reading TSB reports from Canada compared to a US NTSB report. Those privacy laws apply to the living, thus we know very little about the incoming crew but we do know the names of those killed and some details of their service records.

The final report will also detail the trip prior to the incident, we do know that the train was assembled at Red Deer , and that it was recrewed at Calgary, and that mechanical problems had been reported and the train encountered significant delays prior to the incident. If one of the root causes of this incident involves train marshalling or equipment failures, this portion of the report may be being withheld for legal reasons until the final report is published.

Did the outgoing and incoming crew have the opportunity to talk to each other? If not, CP supplied a “crew to crew” form where the outgoing conductor can detail what they have done to secure the train. First item on the form, the number of handbrakes applied.

Could it be that the supervisor assumed that the incoming crew had already applied handbrakes before contacting him/her? Usually, the engineer remains at the controls of the locomotive while the conductor carries out the ground work such as applying handbrakes and retainers, so that there could have been an assumption that handbrakes were being applied as the job briefing was taking place. It could be that in previous incidents, the crew applied the handbrakes first and then contacted the proper authority to ask what to do next.

Likely the evidence collecting portion of the investigation has been completed and it will now go to the hearing portion. How many more details will be released before conclusion? TSB hearings are not criminal investigations but court proceedings can rise out of them.

I’m willing to wait for the final report to find out if anyone was negligent in this incident.

Posted from iPhone



Edited 3 time(s). Last edit at 04/20/19 09:13 by eminence_grise.

Will the supervisor be charged with involuntary manslaughter?  His instructions partly caused this!!

coach Wrote:
-------------------------------------------------------
> Will the supervisor be charged with involuntary
> manslaughter?  His instructions partly caused
> this!!

Jumping the gun just a little bit aren't we?
Howabout we let the professional investigators do their job before we start assigning blame.

Thanks for the detailed explanation of how this process invokes over time.

Posted from Android

coach Wrote:
-------------------------------------------------------
> Will the supervisor be charged with involuntary
> manslaughter?  His instructions partly caused
> this!!

Highly doubtful. To the best of my knowledge, the Criminal Code Of Canada does not include a charge of "involuntary manslaughter."
As others have said ... leave the decision up to those responsible for investigating, and if deemed necessary, laying of charges.


 

Will MacKenzie
Dundas, ON

eminence_grise Wrote:
-------------------------------------------------------
> Did the outgoing and incoming crew have the opportunity to talk to each other? If not, CP
> supplied a “crew to crew” form where the outgoing conductor can detail what they have done
> to secure the train. First item on the form, the number of handbrakes applied.

With the train not secured I would sure hope the inbound crew did not leave the train unattended and instead waited to be relived by the outbound crew.

I also would have hoped they started spinning some hand brakes immediately after the train was placed in emergency, with or without talking to the supervisor. All other issues with the train could wait until help with a higher pay grade arrived, but hand brakes were needed immediately.

Not applicable to this situation since the train wasn't secured, but is it even permissible to leave a secured train unattended on heavy grade territory on the CP?



Edited 2 time(s). Last edit at 04/20/19 15:22 by ble692.

Laggan Subdivision Special Instructions - TT 31 - Nov 28 2012.
[Rules may have changed since that date]

11.3 The train handling procedure on page 5/7, and the
following instructions in paragraphs A, B, C and D
apply to westward freight trains in which the weight
per operative brake is 100 tons or greater.
Note: All westward trains experiencing an emergency brake application beyond mile 123.5 must communicate with the on duty Trainmaster via the RTC
and be governed by their instructions.
A. Emergency brake recovery procedure – If an
emergency brake application is experienced between Stephen and mile 125.5, the train brakes
may be released and the train allowed to proceed to mile 125.5, where it must be stopped
and the brake pipe fully recharged. Trains
which are stopped between mile 125.5 and Signal 1363 Field with the train air brakes in emergency, must be governed as follows:
First Emergency Brake Application:
Before the emergency PCS is recovered, all
crew members (ie: locomotive engineer and
conductor and Trainmaster) must perform a job
briefing to discuss with each other the use of retainer valves. In the application GOI section 15,
item 14.3 and 29.3, set retaining valves to the
HP (high pressure) position on at least 75 percent of the loaded cars.
When discussing the use of retainers and/ or
hand brakes, consider train location, amount of
train on the mountain grade weather and rail
conditions and any other conditions present that
may affect the braking of that train. If abnormal
conditions such as weather or poor braking train
dictate that the application of hand brakes is
necessary to secure the train while re-charging,
then apply a hand brake on at least 75 percent
of the cars and set retaining valves to the HP
position on at least 75 percent of the loaded
cars.
Second Emergency Brake Application:
Apply retainers on 100% of the loaded cars and
40 hand brakes on the head end of train. Allow
the train to fully recharge the brake pipe.
Note: If there is doubt or uncertainty regarding
the continued operation of the train, then contact the RTC and request to speak directly to a
Trainmaster.

[above emphasis mine]
 

The “train handling procedures “ mentioned in the previous post are a timetable feature since the 1970’s.

They detail the “best practices” procedure for handling trains down the Field Hill, and arise out of an extensive audit of train handling practices following a series of runaways in the 1970’s and 80’s.

At the time, older equipment with AB brakes and cast iron brake shoes , with all the power on the head end was being replaced by newer cars with ABD and ABDW brakes , and Locotrol distributed power was coming into service.

After studying operations across the system, new methods of train handling were introduced by the railway.

In regards to westward operation down the Field Hill, the operation was codified.

Cresting the Continental Divide at Stephen, a minimum brake application was to be made and seen to be effective in controlling the speed down the 1 percent grade west of the summit. Following the short downgrade, there is a flat portion of track along Lake Wapta, the site of the former Hector siding. Heavy trains retained the minimum brake application over the flat, because at the west end of the lake, the 2.2 percent grade commenced all the way westward through the spirals.

Partridge siding is a mile or so west of the start of the 2.2 percent grade and is all on the grade.

Trains expecting to stop at Partridge have to make speed adjustments prior to taking the siding.

In this case, the train exceeded the 15 mph speed limit required for trains stopping at Partridge, and the brakes were applied in emergency as required in the instructions.

So far, the incoming crew were following the best practices code and the timetable special instructions.

Of importance to the investigation will be why the train was accelerating over the prescribed 15 miles per hour and whether the brake was applied at Stephen in the best practices manner.

Posted from iPhone

Phil - As always thank you for your insight.  So far it continues to appear that both crews followed procedure. 

OP - I've shared some of the takeaways regarding BCP leakage with co-workers in the States.  Though we don't have grades this extreme, much of the information is still pertinent. 

On the extended railroader grapevine of CP employees, past and present and supervisors, further details regarding the event are circulating.

I’m not going to post them on a public forum, but if the grapevine proves true, expect further TSB releases on both the topics released last week.

Posted from iPhone

ble692 Wrote:
-------------------------------------------------------
> I also would have hoped they started spinning some
> hand brakes immediately after the train was placed
> in emergency, with or without talking to the
> supervisor.

This right here. Nothing else could have been accomplished after the emergency application without this being done first anyway. As cctgm said, I don't think a lot of modern crews understand how retainers work or how to set them up properly. The AB&TH instructions are also inadequate. This will likely boil down to a lack of proper training. Retaining valves are incredibly useful in mountain grade territories under difficult circumstances but they seem to almost be an afterthought in modern training programs. Too much reliance on dynamic brakes these days IMHO.

coach Wrote:
-------------------------------------------------------
> Will the supervisor be charged with involuntary
> manslaughter?  His instructions partly caused
> this!!


Railfan justice.

trainjunkie wrote: "I don't think a lot of modern crews understand how retainers work or how to set them up properly." 

Agreed!