Ten90 Solutions LLC

The Transportation Safety Board (TSB) of Canada has released the results of its investigation into the February 4, 2019, unintended and uncontrolled runaway of Canadian Pacific train 301-349 that resulted in the wreck of the train and the death of three CP employees.

This accident has been written about before (including by me).  The facts are not in dispute.  On February 3, 2019, CP train 301-349, consisting of 112 loaded grain hoppers, a head end locomotive, and two distributed power units, with a train weight of 15, 042 tons and a length of 6676 feet, experienced a near-catastrophic train brake failure while negotiating a 2 percent downhill grade on a section of track known as Field Hill on the Laggan Subdivision. 

The locomotive engineer was unable to control the train speed through service and dynamic braking.  He initiated an emergency brake application that brought the train to a safe stop.

The trainmaster was dispatched to meet with the crew and per published instructions, retainers were set to the HP position on 84 hoppers.  No hand brakes were set.

Due to time constraints a relief crew was dispatched to operate the train the final 13 miles over the Field Hill section.  The grade on this section was 2.2 percent downhill. 

After the emergency application, 301-349 sat for almost 3 hours with outside temperatures at -30 degrees Fahrenheit. 

The relief crew arrived, met with the trainmaster and the "originating" crew.  With the new crew onboard, the train began its undesired runaway, derailing on a 9.8-degree curve, fatally injuring the crew members. 

TSB, Transport Canada (the regulator) and Canadian Pacific all took a number of remediating actions soon after the runaway and derailment. 

This TSB report examines the immediate and "background" circumstances of the incident. It illuminates some very disturbing data and makes a number of recommendations. 

I urge everyone to read the report, all 254 pages in the pdf format. 

The Canadian Pacific Railway issued a statement after the release of the investigation that claimed that "the TSB...misunderstood key facts about the incident in its report." 

CP claimed that:

(1) "the assessment of the situation was made using the collective knowledge of everyone involved;"

(2) that all the employees and the trainmaster were properly trained and qualified and "this  was not an issue of training and/or experience;"

(3) that "the TSB has erroneously concluded, based on inappropriate extrapolation of data and unsupported inferences, that the involved train exhibited poor braking performance.  As confirmed in the report, the train involved was fully funtional, met all industry standards and passed all regulatory brake test inspections;" 

(4) that "CP demonstrated that its Safety Management System contains all necessary elements required by regulations.  CP's safety hazard reporting procedure was effective... There were no systemic hazards that were not appropriately addressed, including Field Hill train braking performance...;" 

(5) that "CP has a robust training and certification program that meets or exceeds applicable regulatory standards...;" 

(6) that "CP has a strong culture of safety and always works to improve." 

Well, I have this to say about all those thats.  If all of those things are true, how did this fatal incident ever occur?

It is simply inadequate, insufficient, and incorrect for CP to dispute the TSB's finding and NOT provide an alternative explanation for the cause of the incident. 

Now, regarding those thats:

(1) Indeed.  The train experienced a catastrophic brake system failure that required an emergency brake application, and no one thought to inspect the train to determine a cause?  Without such an inspection and determination, that train should never have been programmed to proceed. 

(2) Really? Then there is a glaring weakness in those training and qualification systems.  See (1) above. 

(3) The train brakes did not perform poorly?  Then why the need for the emergency application?  For the very same reason that the runaway occurred: sufficient brake cylinder pressure could not be maintained to control the train. 

(3a) Really?  Then we can expect many more train runaways if this train met all "industry standards."  Or... maybe the required brake tests do not tell us everything the industry needs to know to set such standards.  Maybe the required brake tests are measuring only brake cylinder travel, and not the actual retarding force being applied to the train wheels?  You think that's a possibility? 

(4) Really? TSB reports (item 2.8.3.3.1) that "for at least 3 winters before the occurrence, crew had filed hazard reports on this issue [poor braking performance of unit grain trains on Field Hill] regularly through the proper channels. Still year after year, the reports on the poor braking performance of unit grain trains on Field Hill were closed, no risk assessment was conducted and insufficient corrective action was taken." 

(4a) Apparently, CP did not restrict train weight or train length for the extreme conditions that might be encountered in winter in Field Hill. 

(4b) CP had installed wheel temperature detectors to identify "cold wheels" that would indicate ineffective braking.  This data for 5 previous westbound grain trains showed a "high percentage" of ineffective brakes in the 2 cold days prior to the incident.  The report states "CP was not analyzing these data and did not initiate any specific action or corrective measures." 

(5 & 6) I have no doubt that CP believes it has a robust training program and a strong safety culture, but regardless of how robust and how strong these factors are there is a factor that is significantly more robust, more critical, and remains unaddressed, and that is train make-up. Was the make-up of train 301-349 such that the train's operating characteristics could not meet and satisfy the operating requirements for movement over Field Hill?  Did the weight and length of the train impair the ability of a train crew to safely operate the train under extreme conditions? 

Now personally, I think this is a question of critical relevance, perhaps the question of critical relevance as train make-ups grow in weight and length overtime.  Are the operating characteristics such that the operating requirements cannot be satisfied? 

Careful readers will note that in my previous post on this incident I was gob-smacked that nobody applied any hand brakes.  Frightening, yes?  Even more frightening however is the data developed by TSB that showed that there exist conditions when the number of hand brakes required to "hold" the train on the grade exceeded the number of cars in the consist. 

That is one example of a train's operating characteristics failing to meet the operating requirement for safe train movement.

I was trained to never rely on the air brakes to hold a cut of cars on a grade.  The industry needs to keep this in mind before (a) reducing crew sizes to a single person  (b) building its trains. 

We, our industry, need to find, develop, and standardize real measure and tests of braking effort; and then right-size trains for operating requirements, not operating ratios. 

David Schanoes   

April 6, 2022

Name that Tune

Well, she dances to the bop

she dances to the stroll

she dances to the walk

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