The Transportation Safety Board of Canada (TSB) says the failure to use air brakes caused an empty freight car to roll uncontrolled out of Canadian Pacific’s Sutherland Yard and onto the main train track.
TSB released its report Tuesday into the incident early in the morning of March 27, 2016 in Saskatoon.
Investigators found a recently qualified crew had uncoupled the last car of a train in order to leave it on the track, but did not secure it with air brakes.
The crew was interrupted by another freight train requesting permission to enter the yard.
The investigation found the crew decided to reverse the entire train they were working on to allow the second freight train to pass, forgetting that they had uncoupled the last car.
The movement caused the uncoupled freight car to roll uncontrolled through the yard before entering the main track.
The car then travelled for nearly two kilometres, passing through two controlled crossings, before coming to a stop.
There was no derailment and no injuries.
TSB said the incident highlights concerns they have “that current defences are not sufficient to reduce the number of uncontrolled movements and improve safety.”
There have been 541 uncontrolled movements in the last 10 years, according to TSB officials, with 32 per cent directly related to switching without air brakes.
CP has since resumed the use of air brakes and a conventional three-person crew during switching operations at the Sutherland Yard.
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