Canadian Railroads > TSB Update on Field Hill Fatality Investigation

Canadian TSB (Transportation Safety Board) Field Hill Fatality Investigation Update.
Rail transportation safety investigation R19C0015

https://www.tsb.gc.ca/eng/enquetes-investigations/rail/2019/r19c0015/r19c0015.html?fbclid=IwAR2dCPxY6PMOj02jtGXFgYWZSt6XMvPdNFoV-OkkIsAVas7RYnsmgXRG1Z4

So the big question remains. Why did the first crew not secure the train with handbrakes right away?

IIRC, that is part of the rule for that territory and setting retainers while in emergency is pointless unless you can fully recharge the train and make a set, which would have been impossible without securing the train against movement. 

Sounds like either the crew didn't understand how retaining valves work, or somebody higher on the food chain ordered them to do things incorrectly. That's really the primary unanswered part of this tragedy.

If I went into emergency under those conditions, I would have immediately bolted out the door and started spinning brakes. I wouldn't care what some manager was telling me to do, nor would I comply with HOS. You only have one chance to get it right. I've worked in a lot of cold weather and seen how brake cylinders can bleed off right before your eyes. I've had to tie trains down on grades in the snow and sub-freezing temps. You don't sit around waiting for someone to tell you what to do, you secure your train...quickly. The brakes were probably already compromised due to ice build-up on the brake shoes and wheel treads so any loss in brake cylinder pressure was a disaster waiting to happen and the only hope of keeping that thing still would have been to tie it down. Even with every single handbrake tied, I would still be concerned about it moving as the airbrakes released, whether they were released intentionally or not.

And that begs the question. How thorough is CP's training on this with the crews and managers in these territories? Just a guess, but I'm betting that there are inadequacies there too. We'll see when the report is released.

xcnsnake Wrote:
-------------------------------------------------------
> Canadian TSB (Transportation Safety Board) Field
> Hill Fatality Investigation Update.
> Rail transportation safety investigation R19C0015
>
> https://www.tsb.gc.ca/eng/enquetes-investigations/
> rail/2019/r19c0015/r19c0015.html?fbclid=IwAR2dCPxY
> 6PMOj02jtGXFgYWZSt6XMvPdNFoV-OkkIsAVas7RYnsmgXRG1Z
> 4

Much of this information already appeared on those pages when the previous update was issued with a news release on April 18 last year.  What's particularly new here is the info about the new lead investigator, who has replaced the man who voiced his opinions to the CBC in mid-investigation.

The item on the new lead investigator, Peter Hickli, reads as follows:

"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, he has been the Investigator-in-Charge (IIC) of nine rail accident investigations and served as a team member providing technical expertise on several other investigations, including Lac Megantic.

"Prior to joining the TSB, Mr. Hickli worked for BC Rail/CN for 30 years. During that period, he served a 4-year Carman apprenticeship and worked extensively in the Mechanical Department both in a unionized and management capacity.

"He was also a member of the Derailment investigation team and the Hazmat team, as a hazardous materials technician and advanced tank car specialist."
 
 



Edited 3 time(s). Last edit at 02/07/20 21:22 by railsmith.

After a couple of coal train runaways in 1977 and 1981, one of the conclusions reached in the Railway Transport Commission hearings was that engine crews lacked knowledge of the intricacies of air brake system.

Hundreds got to go back to class. We had three "characters" as instructors, two engineers and one carman. Much of the time was a question and answer session. It soon became apparent that we didn't know much but had learned by the "seat of our pants". Some of the students had started on K-Triples and in the 1980's there were many AB and ABD air brakes in service. However the coal trains had ABDW's. What amazed the instructors was that there had been fewer runaways.

We all learned a lot. Both the railway and the employees. Out of the experience came the "Mountain Grade Operation" timetable special instructions.  They have been in place for forty years. "Go in Emergency on a grade, tie on handbrakes before recovering the air brakes" rose out of all that.

When we passed on our wisdom to the next generation of engineers, we made sure our students understood the importance of tying on handbrakes.

I hope CP instructors continued to pass on the wisdom in the classroom.I respect Rail Traffic Controllers (train dispatchers) but it is not their responsibility to understand train air brake systems.I had air brake problems from time to time, but no one in the RTC Centre ever questioned a decision to tie down a train. It was a case of "We are tying the train down, we will let you know when we are ready to proceed".

I know the workplace culture has changed in recent years, and today's employees face suspension or dismissal much more readily than in years past. Everyone talks of workplace intimidation where supervisors threaten dismissal for minor incidents.

I am pleased to know that the TSB conducted interviews and preserved the phone and radio conversations. I'm also glad that the TSB lead investigator is an up through the ranks railroader from another railway.

In regard to the Canadian Hours of Service Legislation, it states that the engineer and conductor will be relieved of the responsibilty of control of the train after 12 hours. Tying down brakes is not considered "control" of the train, however there are penalties for the railway for working a crew over 12 hours in an "Emergency" situation, in the form of minimum day 100 mile payments. 



Edited 4 time(s). Last edit at 02/07/20 14:15 by eminence_grise.

Have they removed the lead locomotive from the river? And are there any photos of it?

Posted from iPhone

For Air Brake education I will re-post my November 29, 2019 post regarding this as it is exactly what TSB is now explaining as the cause of killing 3 crew men.
The TSB immediately gave a reason why the train had no air brakes as they told everyone that the air brake control handle was left in emergency position when the inbound crew left the train. That means the train line is a zero pressure and after 2 or 3 hours the remaining air in the entire train bled off. When the outbound crew move the brake handle away from emergency position, it released what few brake shoes were held against any wheel, and they had an immediate run away. Too bad they did not jump off at that moment.
The remaining question is why the inbound crew did not apply any hand brakes on the train and charged the brake line back up.  Just as if the crew had a beef with the management as they were outlawed on time. 

When the inbound crew stopped the  train for a re-crew they were on short time and to securely hold the train the engineer put the brake handle all the way over to emergency position.  On every car of the train, the control valve senses that the air pressure in the train pipe line has reduced and triggers the valve adding all the 90 pounds held in the emergency part of the air tanks on the car directly to the brake piston.  The brake piston had already had likely 30 pounds of air pressure taken off of the service part of the air reservoir.  So now both ends of the air reservoir, the service half and the emergency half are piped so all the pressure in that tank is applied against the brake piston on the car, and it will stay that way.  Now there is no air pressure in the brake train line and what ever the engines are pumping is going no place and only keeps the supply tanks on the locomotive full at 130 pounds. 
The locomotive control valve is open to the atmosphere so the train line continues to be zero pressure.  Now it is between 10 and 20 below zero F and every piston only has a rubber gaskets to seal the pressure inside the piston and it can leak around the piston gasket and escape.  So in every hour this condition continues, the brakes on every car are releasing regardless of how old the cars are. 
When the new crew got on that train the train it was already to roll away as no hand brakes had been applied but some cars were still retaining some brake piston pressure connected to the emergency part of the car's air reservoir. 

To  proceed travel with the train, the engineer failed to check to see what hand brakes had been applied, and then moved the brake handle away from emergency position  to re-charge the train brake line and put 90 pounds back into the reservoirs on each car of the train, and also restore the 90# that needs to be in the emergency half of those reservoirs.  Now the tripple valve discovers pressure in the train line and it released all the remaining pressure in the brake cylinders so that it can charge up the two half of the reservoirs.  That adjustment of retainers had no change to this action of the tripple valve.  It should have taken about 45 minutes to hour to recharge this train as every seal at every air hose connection on this train would leak a little pressure.  But now the train has very little air in any supply tank on the train, and no pressure inside any piston on the train and the entire train is free to roll which it did on it own.  Only if all the units on the train were put in reverse and throttle up could you prevent its movement.  If that was done, I do not know,  but it had a mid train engine and tail end engine.  The weight of the run away train would just slid or spin the wheels on those engine and not have enough traction to stop the run away train as way too heavy.  Their should be a trial on the inbound crew as leaving the train with no hand brakes to hold it and not have the brakes handle restored to service with full charged train and full brake application.  Then the idle engines would have kept the train charged up so it had full brakes to control it.  Surely a lack of crew knowledge on air brakes rules.

I once was informed by a ICC inspector that crews arriving in my yard had stopped and put the train in emergency rather than making a full service application.  The ICC did not want the system used that way as it put extra stress on the brake piston.  It could show piston that were out of adjustment with excessive piston travel.  I got that procedure stopped and I never heard from the ICC inspector again.

One thing I don't unerstand is you should know when you are going about 25 or 30 mph and can't control the train, it is time to bail. I wonder why the crew didn't bail?  Is there any radio conversation about that in the report? Why was there 3 crewmembers, in case I missed it?

Thanks.

Randy Lundgren
Elgin, TX

There are two sets of crew instructions involved here;

Rules for securing a train unattended at a remote location. (GOI, General Operating Instructions)

Timetable special instructions regarding securing at train and recovering the air brake system at a specified "Mountain Grade Location" (CP Employee Timetable).

Both are required to be complied with before the incoming crew left the train unattended at Partridge BC.

There is a document called a "Crew to crew" form, which the incoming crew fills out for the outgoing crew. Unless the crews meet each other in person, details of how the train has been secured must be written down. Before doing any other duties, the outgoing crew are required to read and understand the instructions on the "crew to crew". For an unattended train, this form requires details of how the train is secured.

The Rail Traffic Controller was usually made aware of how the train was secured. What is troubling is that the crews were allowed to leave the train unattended without hand brakes secured while the incoming crew was transported by track machine to road access and a waiting shuttle van which had bought the relief crew to the track machine.

The "train unattended" GOI was modified following the Lac Megantic tragedy.

As it was when I was working prior to 2005.

Apply sufficient handbrakes to secure the train against movement with the air brakes released . Release the air brakes. Test the handbrakes by releasing the air brakes and
applying traction forward (no higher than throttle 1).  

I understand that this GOI instruction was modified after 2013 to require the locomotive consist be separated from the train, leaving the brake pipe connection on the train open to the atmosphere.

As evidenced by the Greeley incident, the "train unattended" instruction cannot be overridden by a company supervisor unless he can arrange for other staff to secure the train without leaving it unattended (another crew, car staff, supervisory staff).

Crews can be instructed to continue working over 12 hours as long as they are not in control of the train movement. When instructed to work over 12 hours, a supervisor will arrange for financial compensation and also report the reason to higher authority. 

In the past, railway employees responsible for the death of others in Canada have faced "Manslaughter" charges in Federal Court, and have been convicted if "willful negligence" is proven. In 1951, this was still a "capital offence"(death penalty)  that a station operator (telegrapher) faced regarding the Canoe River collision on the CN. A future Prime Minister, John Diefenbaker was able to save the life of the operator .

Brake pipe pressure on freight trains in Canada is 85 psi. 

Partridge BC is at Mile 128 of the Laggan Subdivision (128 miles west of Calgary AB.) and Field BC is at Mile 136.6. Field is the crew change location. Running time for a freight train westbound is about 40 minutes between the two control locations. No mention has been made of why or if a stop was required at Partridge by train 301.

My guess is that the RTC anticipated that 301 had sufficient time to reach the crew change location at Field under the hours of service legislation. Then, for a reason we don't know,
the train went into emergency, and it became imperative to relieve the incoming crew at Partridge, a location with no road access.  There was a ballast regulator adapted for winter use as a snow plow (snow fighter) working at snow clearing between Field and Stephen, and an arrangement was made to transport the incoming and outgoing crews from the train to highway access on the regulator. There must have been considerable radio dialogue between the Rail Traffic Control centre and the incoming and outgoing crews.

We know no details about the inbound crew. Part of the reason is Canada's privacy laws which limit disclosure far beyond those in the US (No court TV, and very limited disclosure by the RCMP) and basically just the names and brief details of the service records of the employees killed. More details regarding "human factors" will be disclosed in the TSB report. This event took place over a year ago. The railway discipline procedure takes place outside the public domain. The surviving crew members will have been subjected to discipline, possibly fired by now. An unfortunate possibilty could be that they have been "held out of service-pending investigation", suspended without pay and not permitted to collect social assistance. Sadly this has been the case in previous incidents. Even purchased "Out of Service" insurance runs out after one year. I'm not in the loop with the unions any more, so I have no knowledge of the fate of the incoming crew in this case. A friend that was involved in a previous incident experienced serious financial stress for his family and himself waiting for the TSB to render a decision so that the railway could decide whether to dismiss him or not. He was re-instated but never compensated for the time out of service.
'

Although the media likes to portray this portion of track as dangerous, few incidents have taken place both on the original 4% grade or the present 2.2% grade involving the Spiral tunnels. Thousands of trains have completed their journeys without incident since 1885.

 



Edited 7 time(s). Last edit at 02/10/20 07:35 by eminence_grise.

PlyWoody Wrote:
-------------------------------------------------------
> For Air Brake education I will re-post my
> November 29, 2019 post regarding this as it is
> exactly what TSB is now explaining as the cause of
> killing 3 crew men.
> The TSB immediately gave a reason why the train
> had no air brakes as they told everyone that
> the air brake control handle was left in
> emergency position when the inbound crew left
> the train. That means the train line is a zero
> pressure and after 2 or 3 hours the remaining air
> in the entire train bled off. When
> the outbound crew move the brake handle away
> from emergency position, it released what few
> brake shoes were held against any wheel, and they
> had an immediate run away. Too bad they did not
> jump off at that moment.
> The remaining question is why the inbound
> crew did not apply any hand brakes on the train
> and charged the brake line back up.  Just as if
> the crew had a beef with the management as they
> were outlawed on time...

Step away from the keyboard Woody. Did you even read what the TSB wrote under "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. (Note: It doesn't saw HOW they were applied, only that they were applied. Even if you have a UDE, the engineer will move the automatic brake handle to the emergency poistion AFTER the emergency application has occurred to reset the PCS, and leave it there until they are ready to recover their air. So that isn't unusual)

• 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. (Note: The most significant detail lies somewhere in here. Why were retainers applied, and not hand brakes? What role did the crew and the supervisor have in this decision?)

• There were no hand brakes applied on the train. (Note: Again, why? Crew decision or orders?)

• 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. (Note: Nothing about the new crew releasing the automatic brake valve handle and nothing claiming either crew tried to recharge the brake system)

• 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 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.  

That's it. That is all they have disclosed.

So, from this, where did you get that "the inbound crew stopped the train for a re-crew they were on short time and to securely hold the train the engineer put the brake handle all the way over to emergency position."? How do you know they were short on time at the time when the emergency application occurred? I don't know how far the next crew change point was but they had 3 hours on the clock from the time the train went into emergency. How do you know they initially stopped to re-crew? Why on earth would they use an emergency application at the top of a grade to "securely hold the train"? How do you know this wasn't a UDE and they just ran out of time trying to solve the problem? And the best one, what makes you think the engineer on the new crew "move the brake handle away from emergency position"?

As usual, you have filled the gaps in with a lot of inflammatory assumptions that you made up in your head. While some of your assumptions may turn out to be correct, nobody actually knows at this point, including you. What the TSB diclosed at this point only creates more question than answers. But I'll give you credit for not calling the first crew murderers this time.



Edited 1 time(s). Last edit at 02/10/20 06:48 by trainjunkie.

trainjunkie Wrote:
-------------------------------------------------------
> PlyWoody Wrote:
> --------------------------------------------------
> -----                *Incorrect*
> > For Air Brake education I will re-post my
> > November 29, 2019 post regarding this as it is *not*
> > exactly what TSB is now explaining as the cause
> of
> > killing 3 crew men.
> > The TSB immediately gave a reason why the train
> > had no air brakes as they told everyone that
> > the air brake control handle was left in
> > emergency position when the inbound crew left
> > the train. That means the train line is a zero
> > pressure and after 2 or 3 hours the remaining
> air
> > in the entire train bled off. When
> > the outbound crew move the brake handle away

PlyWoody, it is obvious that you did NOT read the TSB report fully and with understanding!   Nowhere in that entire report does it say that "according the the event recorders, the engineer released the brakes..."

A qualified engineer would never release the automatic brake before checking for handbrakes with the conductor, just because of this type of thing happening!  

Yet you print that he did it, contrary to the TSB Report, and with NO first-hand knowledge.
> > from emergency position, it released what few
> > brake shoes were held against any wheel, and
> they
> > had an immediate run away. Too bad they did not
> > jump off at that moment.
> > The remaining question is why the inbound
> > crew did not apply any hand brakes on the
> train
> > and charged the brake line back up.  Just as
> if
> > the crew had a beef with the management as they
> > were outlawed on time...
>
> Step away from the keyboard Woody. Did you even
> read what the TSB wrote under "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. (Note:
> It doesn't saw HOW they were applied, only that
> they were applied. Even if you have a UDE, the
> engineer will move the automatic brake handle to
> the emergency poistion AFTER the emergency
> application has occurred to reset the PCS, and
> leave it there until they are ready to recover
> their air. So that isn't unusual)
>
> • 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. (Note: The most significant
> detail lies somewhere in here. Why were retainers
> applied, and not hand brakes? What role did the
> crew and the supervisor have in this decision?)
>
> • There were no hand brakes applied on the
> train. (Note: Again, why? Crew decision or
> orders?)
>
> • 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. (Note: Nothing
> about the new crew releasing the automatic brake
> valve handle and nothing claiming either crew
> tried to recharge the brake system)
>
> • 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 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.  
>
> That's it. That is all they have disclosed.
>
> So, from this, where did you get that "the inbound
> crew stopped the train for a re-crew they were on
> short time and to securely hold the train the
> engineer put the brake handle all the way over to
> emergency position."? How do you know they were
> short on time at the time when the emergency
> application occurred? I don't know how far the
> next crew change point was but they had 3 hours on
> the clock from the time the train went into
> emergency. How do you know they initially stopped
> to re-crew? Why on earth would they use an
> emergency application at the top of a grade to
> "securely hold the train"? How do you know this
> wasn't a UDE and they just ran out of time trying
> to solve the problem? And the best one, what makes
> you think the engineer on the new crew "move the
> brake handle away
> from emergency position"?
>
> As usual, you have filled the gaps in with a lot
> of inflammatory assumptions that you made up in
> your head. While some of your assumptions may turn
> out to be correct, nobody actually knows at this
> point, including you. What the TSB diclosed at
> this point only creates more question than
> answers. But I'll give you credit for not calling
> the first crew murders this time.

PlyWoody's post can be best described as the same type of reporting we all complain about, inaccurate, and full of imagination.
The asteriskes * at the top of the page are mine, to identify the re-posted errors.
G 

texchief1 Wrote:
-------------------------------------------------------
> One thing I don't unerstand is you should know
> when you are going about 25 or 30 mph and can't
> control the train, it is time to bail. I wonder
> why the crew didn't bail?  Is there any radio
> conversation about that in the report? Why was
> there 3 crewmembers, in case I missed it?
>
> Thanks.
>
> Randy Lundgren
> Elgin, TX

The full report has not been issued yet. The brief summary of initial findings posted at the TSB site does not cover those questions.



Edited 2 time(s). Last edit at 02/09/20 15:01 by railsmith.