Investigation into CP Rail train #301 wreck at Sprial Tunnels by CBC

[SD70Dude]

BaltACD

The red paragraph as written is very ambiguous - when it says that the crew 'had not yet recovered the air brake pressure from the emergency brake application.  

Does this mean that the Engineer had placed his brake valve in the Release position and was attempting to 'pump off' the Emergency application?  Or does it mean that the brake valve had been left in emergency and the train started rolling while the emergency application was still applied. 

I interpret that phrase to mean that the locomotive brake handle was still in the emergency position, and the Engineer had not yet moved the handle to the release position in order to attempt to recharge the train. 

Like your NTSB, our TSB has no power to officially assign blame to individuals or entities, and must write reports very carefully in order to not overstep its bounds.

I don't think this arrangement is ideal, but it is the current reality.

[SD70Dude]

Euclid

SD70Dude,

Thanks for that explanation.  So as I understand you, the Ministerial Order issued after the accident was not a change in rules.  It merely reaffirmed existing rules because they had been misunderstood in the case of this accident.  Apparently that misunderstanding was that it was okay to delay setting hand brakes after the train stopped.  And apparently that delay was due to waiting for the second crew to arrive to begin setting handbrakes in order to recover the air. 

The misunderstanding was the thinking that as long as a employee was onboard or beside the train it was not "unattended", and therefore handbrakes did not legally need to be applied.

Convieniently, this meant that the first crew did not have to undertake the arduous physical task of applying dozens of handbrakes. 

I myself "convieniently misinterpreted" this rule in the past, though not in heavy grade territory.  I do not work that way anymore. 

Euclid

From the TSB report:

“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.”

This indicates that the second crew was only engaged in setting handbrakes for 10 minutes.  According to what you were told by someone familiar with the accident, the engineer was on board the engine while the other two crewmembers were out setting handbrakes.  So they got 10 minutes into that task and the train began to roll away on its own.  The two men setting handbrakes were able to sprint forward and catch the engine before it got away from them. 

I interpret this bit of information from the TSB to mean that the train started rolling 10 minutes after the taxi containing the relief crew arrived at the train.  The inter-crew job briefing and the new crew boarding the lead locomotive and stowing their bags would have taken close to 10 minutes, so I find it likely that the Conductor and Trainee had only spend 2 or 3 minutes applying handbrakes when the train began to roll.

The information I received is secondhand, but it came from a person within my Union who has been a reliable source in the past.  I would not repeat it here if that were not the case. 

But it is not official information.

Euclid

It was said that upon stopping, the first crew turned up the high pressure retainers.  However, it seems to me that the retainers would have been useless with the cylinder packing leaking on most of the cars, as we now know it was. Because the cylinder could not hold pressure due to leaking packing, the high pressure retainer would have no effect.  The retainer would retain the set, but the set would leak off through the cylinder packing. 

This now all makes sense as the full explanation of what happened.  For whatever reason, I can understand the crew not jumping off when the train ran away.  If for no other reason, it would be hard to let the train go with the prospect of later explaining that when there might just be some way to save it.  And then once you get up to 40-50 mph, it would be really hard to decide whether jumping off would be safer than riding it out. 

That is my understanding as well.

When everything is working properly, a retainer set to the "high pressure" position keeps about 20 PSI in the brake cylinder, which is about the same as a minimum service application of the automatic brake.

On properly maintained cars in warmer weather this, combined with the dynamic braking of three AC locomotives and the 1x1x1 DP configuration of the train likely would have been enough to slow acceleration of the train enough that it could be recharged 'on the fly', and then have enough service braking capability to proceed downgrade safely.  This is the theory behind CP's operating instructions as they existed at the time of this incident.

Of course, leaky cars and cold weather appear to be major factors in the poor braking performace that led to the Engineer putting the train brakes in emergency in the first place.