An investigation into a train derailment in Coalhurst found that adaptations to procedures played a factor. Photo by Stephen Strand
An investigation into a train derailment in Coalhurst found that adaptations to procedures played a factor.
Just before midnight on February 11, 2024, a Canadian Pacific yard crew, doing business as CPKC, was attempting to connect 66 railcars to a set of stationary cars using a remote-control locomotive system.
While the railcars were reversing toward the stationary cars, an inaccurate estimate of the remaining distance for coupling had resulted in a collision with the stationary cars and the subsequent derailment.
Even though there was a derailment, no injuries were reported and no dangerous goods were released.
As a result of the investigation, it found that the crew’s witching practices involved multiple adaptations from written instructions, which reduced the safety margins those procedures were intended to provide.
On top of that, the employee providing the distance information was doing so by a portable two-way radio while driving a vehicle, which was dividing his attention.
Consequently, the combination of high cognitive load and reduced visibility at night had affected his ability to provide an accurate distance estimate instructions to the foreman.
After the 11-railcar derailment, Transport Canada inspected the rail yard and issued a letter of non-compliance.
In response to the letter of non-compliance, CPKC conducted a formal investigation and coached crew members on the rules,
Also, the company conducted job briefings and a safety blitz to educate the local crews on the occurrence.
In addition to that, CPKC issued an operating bulletin requiring all crew members pushing equipment on non-main track must have a qualified employee riding the leading piece of equipment while controlling the movement.
Following the response and corrective measures, Transport Canada issued a letter acknowledging sufficient action taken.
To see the full report, click here.
Comments