Several safety infractions caused a fatal train derailment of a White Pass and Yukon Route work train in 2006, according to Canada’s Transportation Safety Board.
The derailment killed one man and seriously injured three more.
The train was too heavy; each car was overloaded and the locomotive was pulling more cars than it could handle, said the board’s 32-page report, issued Thursday.
Train maintenance records were not kept, brakes on some ballast cars were not adequate and there were no markers explaining weight limits or loading procedures.
Also, none of the personnel were trained on car capacity and loading, how to use the brake equipment or how to deal with emergencies.
“They took what they thought was safe because that’s how they were educated,” said Terry Toporowski, regional senior investigator for railways and pipelines at the board.
“There were no regulations on how many cars it could take, there was no guidelines on the weight on the train, and no guidelines on how to load them,” he said.
And there was no risk analysis done in regard to speed, he added.
Safety deficiencies on the White Pass and Yukon Route were identified in 2003, but Transport Canada “missed an opportunity to rectify” them, said Dan Holbrook, manager of western regional operations for railways and pipelines at the safety board.
“Transport Canada is focusing the bulk of its attention on the class 1 transcontinental railways,” he said.
“It appears that the development of the safety system on the White Pass and Yukon Route went somewhat under the radar screen.”
In 2003, Transport Canada told the White Pass and Yukon Route railway that it had failed tests in nine out of 10 safety risk areas.
They were mainly regulatory issues, said White Pass president Gary Danielson.
The company put in a safety plan and had it approved by Ottawa.
The route runs through perilous mountain terrain from Skagway through the White Pass to Carcross. It carries 500,000 tourists a year.
But Ottawa never followed up to see how regulations were being implemented.
Three years later, the train derailed.
According to the board, the crew members weren’t trained to deal with a runaway locomotive.
“(The crew were) passing down information by word of mouth almost,” said Toporowski.
On September 3, 2006, during the tourist off-season, the White Pass crew decided to load eight ballast cars at Log Cabin, British Columbia, before heading north.
Previously, the crew had never taken more than four.
The load was so heavy that the train had trouble moving after filling the seventh car.
So the crew put four cars onto a side rail, filled the eighth car, and the four released cars were re-attached.
The train’s engineer and two heavy equipment operators sat inside the locomotive, while the conductor stood on a platform outside the cab.
Three kilometers out of Log Cabin, the train performed a controlled stop to set brake retainers in a high-pressure position. Retainers are used on air brakes to conserve pressure to provide better brake control.
The brakes were released and the train slowly began rolling.
A kilometre and a half farther, the train entered a curve and its speed climbed to 19 kilometres per hour. The engineer held onto the brake for 30 seconds for the pressure to rebuild before pushing on the automatic brake.
But the train’s speed only increased.
The engineer then put pressure on the independent brake to regain control.
Soon the train hit 28 kilometres an hour, and the engineer slammed the automatic brake, bringing it close to full capacity.
Smoke began flowing from the wheels.
At 32 kilometres an hour, the engineer realized the train was a runaway and made an emergency call.
But there was no radio reception and no one heard the call.
The train kept gaining speed.
After another 1.5 kilometres, the runaway train hit a deadly 16-degree left-hand curve.
The conductor jumped off the speeding train and fell into a small stream.
The train then left the rails and crashed into the earth along the bend, destroying six cars.
The engineer and the two heavy equipment operators were trapped inside the cab.
One of the operators was half buried under rubble. After extricating himself, he was able to revive the engineer.
They radioed the railroad’s road master, who was following the train on a track motorcar.
The road master found the trapped crew. He then found the conductor incapacitated in the stream and pulled him from the water.
Emergency medical services from Tagish and Skagway arrived an hour after the road master used his radio for help.
The rescue effort was mired by radio trouble and relay stations had to be set up to organize the first responders.
The conductor was flown to hospital. Emergency crews freed the equipment operator an hour an a half later.
The deceased equipment operator took another three hours to unearth.
His body was buried in the nose of the locomotive.
The safety board has demanded changes to the route’s safety precautions.
White Pass and Yukon Route must now provide full training on safety, better maintenance of the cars, operating instructions in mountain territory and ballast car loading procedures.
The train was also not allowed to run until secure radio communication could be established between Bennett and Carcross.
“We’re comfortable that the actions we reported on are commenced and are underway,” said Holbrook.
The railway has also provided training for personnel on loading limits, installed retainers on all ballast cars and trained crews on how to use them.
The company also purchased a satellite phone for the route north of Bennett and hired a full-time safety manager.
But it’s unusual these actions weren’t taken earlier.
“You would expect a railway, particularly a railway operating in an extremely mountainous area, to have well-defined and concise operating practices,” said Ian Naish, director of railway/pipeline investigations for the board.
“(You would expect) practices that guided employees on the maximum loads that their rolling stock can carry, or practices and procedures on how rolling stock were maintained, and training regimes that would ensure that employees knew how to operate the equipment that they were working with,” said Naish.
The White Pass route is a small-fry on Transport Canada’s to-do list, but it’s more popular and more dangerous than most small-scale heritage trains.
“It (has more riders) than any other heritage railway that I’m aware of,” said Naish.
It’s one of the few heritage railways under federal jurisdiction and the board has not dealt with any safety issues with other heritage trains in the country, he said.
Under the radar from regulators, these locomotives rely on their crew’s know-how to keep them safe.
The train’s engineer had 29 years of experience while the conductor had worked for the railway for 26 years.
But experience wasn’t enough to prevent the deadly derailment.
“There were no rules in place to prevent them from doing what they did,” said Toporowski.
Contact James Munson at firstname.lastname@example.org.