The federal Transportation Safety Board is blaming a 2006 derailment that killed two workers and seriously injured a third on a decision by Canadian National to replace a braking system without a formal risk assessment.
"Peeling back the layers of the onion, the fact that this business decision was taken to remove locomotives equipped with a supplementary braking system from this territory becomes particularly important," Dan Holbrook, Western Canada manager of the board's rail-pipeline investigations branch, said in an interview.
The board's report notes that although employees spoke among themselves of their concerns about the use of locomotives without so-called dynamic brakes, the issue was not raised with management before the crash, meaning "an opportunity was lost to resolve this safety issue."
As a result, a CN freight train travelling south on June 29, 2006, toward the southern Interior community of Lillooet ran into trouble.
Struggling to control the train on steep Fraser Canyon terrain, the locomotive engineer tried the brakes several times, but the effort failed to bring things under control and the locomotive and flat car came off the tracks, plunging almost 300 metres. Crew members Don Faulkner, 59, and Tommy Dodd, 55, were killed. Engineer Gordon Rhodes suffered serious injuries.
"The derailment occurred after the runaway train reached a speed at which it could not negotiate the sharp curves while descending the long, steep, mountain grade. The train set-up, without a locomotive equipped with [a]dynamic brake and with a single loaded car, resulted in a high gross weight for the braking capacity available from a small number of operative brakes," the report says.
With dynamic brakes, the risk of a loss of control would have been reduced.
When the system was operated by BC Rail, locomotives were equipped with dynamic braking systems, but CN removed such locomotives after they acquired the operation in 2004, replacing them with older locomotives.
"We know the decision was a financially motivated decision but what's important to the safety board and from a safety-accident investigation perspective is that they didn't perform the required risk assessment, required by their safety management system before making this significant operational change," Mr. Holbrook said.
Asked whether he thought CN made a mistake, Mr. Holbrook said "I think that's an accurate way to look at it."
He added: "Of course, looking back at an accident, our vision is always 20-20, but we know that in railway operations there are potential risks and we know that those risks have to be identified and compensated for and that's why the board has made its recommendation concerning the proper performance of risk assessment."
He noted that he was not linking the purchase of BC Rail to this accident and others in the region.
Kelli Svendsen, a CN spokeswoman, declined detailed comment on the board's report due to legal action by the families of the victims, but said the company has been working to improve safety.
She noted a 31-per-cent reduction in main-track accidents between 2007 and 2009 to date, and a 29-per-cent reduction in non-main-track accidents.
Anne Fairfield, the sister of Mr. Faulkner, issued a statement in which she thanked the board "for their care, discipline, and dedication to getting the facts out."
In a subsequent interview, the Hamilton-area resident said she thought the accident was preventable.
"This was a runaway. It could have been prevented. I don't think the company took the reasonable steps to make sure this didn't happen. The big question is why?"
Jeff Dolan, a spokesman for the Office of the Chief Coroner of B.C., said the office has been pursuing an ongoing investigation into the derailment since it occurred and will review the board report as part of the effort that, at this point, will lead to a coroner's report.
Mr. Dolan said the chief coroner could call a full-fledged inquest into the case, but that a decision on this possibility has not yet been made.