Canada - When Canadian Pacific Railway's (CP) doomed Train 301 left Calgary in early February 2019 heading into the B.C. mountains bound for Vancouver, crew members had no idea it was on a death ride.
 
Workers in CP's rail yard had done the required visual brake inspection of the train's 112 loaded grain cars before it left.
 
But the train encountered problems at the top of British Columbia's dangerous Field Hill.
 
Its brakes failed in frigid temperatures as the train sped uncontrolled downhill, derailing mid-mountain, and killing the three crew members on board.
 
This week, the Transportation Safety Board (TSB) released a rail safety advisory, warning that Transport Canada (TC) and CP have known since at least 2018 that those visual inspections do not "reliably identify ineffective brakes in rail cars."
 
"An alternate approach to determining the effectiveness of freight car air brakes is required to ensure that departing trains have sufficient effective brakes to operate safely," stated the advisory that was sent to TC.
 
Ian Naish, a rail safety consultant who served as TSB director of rail crash investigations for more than a decade until 2009, said it's a dangerous situation that TC can't ignore.
 
"If they don't fix it, you're going to have another Field Hill situation. If you're going down a hill with a loaded freight train, a grain train, and the risk is high that you can have a runaway train, then that's dangerous. You can damage a lot of equipment, damage a lot of property, and then you can have severe injuries or fatalities on top of that," Naish told CBC News.
 
He Could be Alive Today
 
Les Paradis, the father of conductor Dylan Paradis who was killed in the Field Hill crash, said the railway and regulators failed to fix a known problem.
 
"He could be alive today. They let something happen that didn't have to happen. The cost is too much. One death is too much," said Paradis, himself a retired CP conductor with 39 years of experience, on reading the TSB's advisory.
 
CBC News asked TC for its response to the TSB advisory and why it has not mandated an alternate inspection system.
 
"TC is reviewing the letter and is determining next steps. We will not hesitate to take action to further protect the safety of the rail system," it said in an email.
 
2015 study
 
The TSB's rail safety advisory details how TC, the National Research Council, and CP in 2015 launched a major study and found alarming safety gaps.
 
Researchers inspected 44 grain trains using only visual inspections (all that is currently required by TC) and found five rail cars with defective brakes.
 
(There are about 100 to 110 cars in a grain train.)
 
But when they tested the same trains again with a newer, automated inspection system, they discovered an astonishing 695 cars had faulty brakes.
 
That report was finalized in October 2018, but since then, the requirements for inspections have not changed, and TC has not mandated the use of the automated system to identify brake defects and pull cars out of service.
 
"There's no runaway trains unless there's something wrong. That new method there would have saved them," Paradis said.
 
After the crash of Train 301, the TSB tested the brakes on 13 of the train's grain cars that had remained upright and undamaged.
 
Brakes on all 13 rail cars failed, despite the train having passed a visual inspection in Calgary the day before.
 
Calls for Tougher Inspections
 
TC has known for years about the problems but has so far failed to set higher standards, says the former TSB director.
 
"Why on earth haven't they taken action yet?" said Naish.
 
Since the February 2019 accident, both CP and CN have repaired a range of problems on thousands of aging grain hopper cars, taking more than 500 out of service permanently.
 
CP said it has beefed up brake inspections following the accident and is working with TC to expand the use of automated tests in the coming years.
 
The TSB investigation into the Field Hill brake failure is ongoing and is expected to deliver its findings by early next year.
 
Warning Signs
 
The TSB's rail safety advisory this week also points to other red flags, including health and safety complaints filed by CP train crews about brake problems in the B.C. mountains.
 
A CBC News investigation earlier this year reviewed dozens of those complaints dating back to 2016, including several that warned about problems specifically on Field Hill.
 
"What can be done to ensure we do not have issues controlling trains on Field Hill?" asks one employee in a safety hazard report.
 
The day before the Train 301 crash, engineer Andy Dockrell was taking a different grain train down the same Field Hill and experienced problems.
 
He radioed ahead declaring he was having trouble slowing the train.
 
He managed to stop and filled out one of the safety hazard reports.
 
But it appears it was never filed.
 
Instead, investigators found it the next day among the crumpled wreckage of train Dockrell was operating when he and his fellow crew members were killed.
 
Author unknown.