Citing a combination of inadequate train handling and employee fatigue as contributing factors, the Transportation Safety Board of Canada (TSB) released its investigation report (R16C0012) into the 2016 Canadian Pacific Railway (CP) derailment in Alyth Yard in Calgary, Alberta.
The accident occurred on February 18, 2016 in the early morning, when a CP freight train was performing a switching operation in Alyth Yard. While moving at approximately 2.5 mph over a short distance within the yard, a power increase in excess of the maximum throttle position for the area was applied. The investigation determined that excessive pulling force produced by the locomotives over-stretched the train as it was traveling through a curve. With the train brakes at the rear of the train not yet fully released, 13 cars derailed when several wheels came off the rail after climbing the inside rail. There were no injuries and no dangerous goods were released.
Specific train handling requirements relating to the maximum locomotive throttle for the occurrence location were not followed. In this occurrence, there was no requirement for the operating crew to review the relevant train handling material prior to initiating a train movement. Furthermore, there was nothing in the operating environment to remind the crew that there was a change in operating requirements at that location.
The investigation also raised fatigue management as a contributing factor, as a crew member was likely fatigued after having had poor quality sleep in the two weeks prior and having been awake for 23 hours at the time of the occurrence.
Fatigue management is a shared responsibility, states the TSB. Employees have a responsibility to make every effort to report to work well rested while the company has a responsibility to provide a system that allows them to do so, including procedures to remove themselves from eligibility for duty without fear of discipline. Fatigue management systems for train crews are a Watchlist 2016 issue. As this occurrence demonstrates, fatigue continues to pose a risk to the safe operation of trains, particularly freight trains, which move 70% of the Canada’s surface goods. The initiatives taken to date have been inadequate to fully address the issue. Fatigue management systems for train crews will remain on the TSB Watchlist until Transport Canada completes its review of railway fatigue management systems; and TC and the railways implement further actions to effectively mitigate the risk of fatigue for operating crew members on freight trains. See the investigation page for more information.