A CN train that derailed near Squamish, B.C., spilling caustic soda that killed hundreds of thousands of fish, was put together incorrectly at the rail yard, the Transportation Safety Board says.
In its final report released Wednesday the board said the locomotives moving the train on a slight ascent were improperly configured and that the crew running them was also not trained properly in their use.
CN instituted long trains for its runs but did not use local knowledge and experience in operating those long trains, the board said.
The board says its investigation revealed significant safety issues related to train operations and the use of technology. The report also calls for CN crews to be better trained for the locations they operate their trains.
The Cheakamus River's population of fish were virtually wiped out in 2005 by the spill of sodium hydroxide into the river, which is located about an hour's drive north of Vancouver.
Nine cars derailed, including one tank car that ruptured, spilling approximately 40,000 litres of sodium hydroxide, also known as caustic soda.
The spill killed more than 500,000 fish from 10 different species and caused extensive environmental damage. The board investigation uncovered safety deficiencies in the Canadian railway transportation system and some of them still have not been addressed.
"The Squamish subdivision is one of the most challenging railway lines in Canada," Wendy Tadros, chairwoman of the board, said in a prepared statement.
"It is not like operating between Edmonton and Winnipeg, or even between Vancouver and Jasper. This is an extreme mountain environment with curves that are twice as sharp and grades more than twice as steep as on other CN main lines. There is no room for error."
The B.C. government sold B.C. Rail to CN in 2003.
The board found that, the day before the accident, when the seven locomotives in the distributed power train were readied for the trip, a locomotive equipped with older technology was set up in the front.
The two mid-train locomotives were also set up to pull in the opposite direction from the head end.
Alarms briefly sounded to indicate a fault and the mid-train locomotives automatically shut down. The crew had no indication of the inoperative state of the mid-train locomotives.
With the mid-train locomotives not working, pulling power came from the locomotives at the front of the train. As the train neared a bridge over a canyon, the long train was slowing down in an area of sharp curves and steep grades.
When another locomotive at the head end was powered up to prevent a stall, the light, empty cars behind "stringlined" to the inside rail of the curve, resulting in a derailment.
Lack of training and proper supervision also contributed to this derailment, the board said.