Cold weather and brake failure led to fatal 2019 train crash: TSB

An investigation into a deadly 2019 locomotive derailment near Field, B.C. has found the train's aging brakes failed due to cold temperatures. 

The Transportation Safety Board of Canada (TSB) released its extensive, long-awaited report on Thursday. It goes into great detail about what happened the morning three Canadian Pacific Railway employees were killed on the job. 

Those findings also come with safety recommendations that look to improve the working conditions of CP's machines. 

Investigators say one of its trains was parked on a grade near the Alberta-B.C. boundary in February 2019, when it started rolling on its own. 

At one point, as it travelled downhill, it reached a speed of 85 km/h, far above the limit for the mountain pass. 

It eventually derailed at a curve in the tracks, where 99 grain cars and two locomotives plummeted off a bridge.

Three men on board were killed including conductor Dylan Paradis, engineer Andrew Dockrell and trainee Daniel Waldenberger-Bulmer. 

REPORT'S FINDINGS

The safety board said its findings show an inbound train engineer had warned the trainmaster of brake system irregularities, but they were not seen as problematic.

In fact, Dockrell had prepared a safety report about the dangerous stretch near Field just one day before he died. 

"(CP has) been receiving reports for several years," TSB regional manager Dan Holbrook said. "It was a recurring issue, and yet there wasn't sufficient action taken to prevent it from reoccurring."

"It's obvious that more needs to be done to reduce the risk 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," added TSB chair Kathy Fox. "The safety hazard report (Dockrell) had prepared about the event was recovered from the accident site, but he never had the opportunity to submit it."

The investigation also accuses the trainmaster's training and experience of not adequately preparing him to evaluate the circumstances or to make on-the-fly emergency decisions.

The TSB's report says brake cylinders on the freight cars were leaking compressed air and, worsened by their age and condition and extreme cold, reached a critical threshold before giving out.

Temperatures reached -28 C on the evening of the crash. 

TSB BOARD'S THREE RECOMMENDATIONS

The TSB board has since made multiple recommendations to Transport Canada to enhance the safety of train operations in cold weather. They include a requirement to install automatic parking brakes on cars — a third option that can be used to slow out-of-control freight. 

Another recommendation asks companies to establish enhanced testing standards for brake cylinders operating on steep grades in cold temperatures. 

The third and final TSB recommendation suggests CP demonstrates a stronger safety management system that is able to identify hazards. 

REACTION FROM DYLAN PARADIS' FAMILY

But the family of Dylan Paradis aren't satisfied. 

Pam Fraser, Dylan's mother, tells CTV News she's worried about the very nature of the investigation. 

"It doesn't bring me more closure," she said. "The report can only make recommendations. (The TSB) has no power to make them actionable. So while they may be good, there is no historical evidence that they will be implemented."

The derailment started an ongoing criminal investigation by the RCMP. 

The families of two of the victims filed a lawsuit last April alleging negligence against Canadian Pacific, its CEO, board of directors, CP police and the federal minister of transport.

They accuse the rail company of cutting corners to make more money, while ignoring basic health and safety. 

CP disputes that claim. 

Thursday, the TSB board acknowledged "multiple factors" led to the crash, but its investigation pointed the finger multiple times and problems with CP's approach.  

"We can't undo what's happened," Fox said, "but what we can do is make recommendations so these sorts of things don't happen again"

CP has removed the involved cars from service since the crash. 

With files from The Canadian Press