When the Canadian Pacific Railway's doomed 301 train left Calgary in early February 2019 for the B.C. In the mountains bound for Vancouver, crew members had no idea they were on a deadly ride.
Workers in the CP rail yard had done the necessary visual inspection of the brakes of the 112 loaded wagons before leaving.
But the train encountered problems at the top of dangerous Field Hill in British Columbia. His brakes failed in cold temperatures, when the train accelerated wildly downhill, disrupting the middle of the mountain and killing the three crew on board.
This week, the Transportation Safety Board (TSB) released a railway safety warning, warning that Transport Canada and CP have known since at least 2018 that these visual inspections "do not safely identify ineffective rail brakes".
"An alternative approach is needed to determine the effectiveness of wagon aerial brakes to ensure that departing trains have sufficient effective brakes to operate safely," said the statement sent to Transport Canada.
WATCH Former TSB director on what's at stake if Transport Canada doesn't fix rail brake failures:
Ian Naish, a railway safety consultant who served as TSB's director of railway accident investigations for more than a decade until 2009, said it was a dangerous situation that Transport Canada has known for some time.
If they don't, you will have another situation at Field Hill.– Ian Naish, former TSB director of railway accident investigations
"If they don't, you will have another situation at Field Hill," Naish told CBC News.
"If you're going down a hill with a loaded freight train – a grain train – and the risk is high that you could have a runaway train, that's dangerous. You can damage a lot of equipment, damage a lot of properties, and then you can have serious injuries or fatalities in addition ".
"He could be alive today & # 39;
Les Paradis, the father of driver Dylan Paradis, killed in the Field Hill accident, said the railroad and regulators were unable to resolve a known problem.
"They let something happen that didn't have to happen. The cost is too much. One death is too much."
CBC News asked Transport Canada to respond to the TSB statement and why it did not determine an alternative inspection system.
"Transport Canada is reviewing the letter and is determining the next steps," he said in an email. "We will not hesitate to take steps to further protect the safety of the rail system."
The TSB Railway Safety Statement details how Transport Canada, the National Research Council and CP were launched in 2015 a great study and found alarming security gaps.
The researchers inspected 44 grain trains using only visual inspections (all that is currently required by Transport Canada) and found five cars with defective brakes. (There are about 100 to 110 cars on a grain train.)
But when they tested the same trains again with a newer automated inspection system, they found that 695 amazing cars had defective brakes.
what report was completed in October 2018.
"There are no uncontrolled trains, unless there is something wrong. This new method would save them," said Paradis.
After the train 301 accident, the TSB tested the brakes on 13 of the wagons that remained upright and undamaged. The brakes on all 13 cars failed, although the train underwent a visual inspection in Calgary the day before.
Calls for stricter inspections
Transport Canada has known about the problems for years, but has failed to set higher standards, says the former TSB director.
"Why the hell haven't they taken action yet?" said Naish.
Since the February 2019 crash, both CP and CN have corrected a number of problems in thousands of cars with a hopper, leaving more than 500 permanently out of service.
CP said it has stepped up brake inspections after the accident and is working with Transport Canada to expand the use of automated tests in the coming years.
TSB's investigation into the Field Hill brake failure is ongoing and is expected to present its findings early next year.
TSB's rail safety warning this week also points to other red flags, including health and safety complaints made by CP train crews about brake problems in the B.C. mountains.
AN CBC News investigation Earlier this year, we reviewed dozens of these complaints that date back to 2016, including several that warned of problems specifically at Field Hill.
"What can be done to ensure that we have no trouble controlling trains at Field Hill?" asks an employee in a security risk report.
WATCH Exclusive video of CP train derailment wreckage in B.C. in February 2019:
The day before the 301 train accident, engineer Andy Dockrell was taking a different grain train down the same Field Hill and had problems. He broadcast a radio stating that he was having trouble slowing down the train.
He managed to stop and filed one of the security risk reports.
But it looks like it was never filed. Instead, investigators found him the next day among the wreckage of the train that Dockrell was operating when he and his crewmates were killed.
WATCH: Fifth Estate's investigation of a fatal CP train crash: