Cause
Why the freight train failed to stop was unclear. A wrong-side signal problem was eliminated, leaving human error as the only possible cause. However, since the head-end crew of the freight train did not survive, it was not clear why they had erred. However, enough of their remains were found that testing was able to rule out drugs or alcohol as the cause. It was also revealed the engineer, Hudson, was an alcoholic and heavy smoker suffering from pancreatitis and diabetes, thus placing him at risk for a heart attack or stroke.
A Commission of Inquiry investigated the crash. Mr. Justice René P. Foisy, Court of Queen's Bench of Alberta, held 56 days of public hearings and received evidence from 150 parties. The inquiry report was published on January 22, 1987. Instead of condemning any one individual, it instead condemned what Foisy described as a "railroader culture" that prized loyalty and productivity at the expense of safety. As an example of this disregard of safety, it was noted that the crew of that train had boarded the locomotive at Edson "on the fly". While the locomotive was moving slowly through the yard, the new crew would jump on and the previous crew would jump off. While this method of changing crews saved time and fuel, it was a flagrant violation of safety regulations requiring a stationary brake test after a crew change. Management claimed to be unaware of this practice, even though it was quite common. In regards to engineer Hudson, the Foisy Commission concluded it was a possibility that Hudson had either fallen asleep at the controls or had suffered a heart attack or stroke in light of his extremely poor health, leading to the collision. The commission further criticized CN's ineffective monitoring of Hudson's health condition:
The serious nature of Hudson's medical condition...raises a strong possibility that it was a factor contributing to the collision of February 8...The Commission therefore concludes that Hudson's medical condition possibly contributed to his failure to control Train 413. The Commission also concludes that there are serious deficiencies in the manner in which CN monitored and reacted to that condition. The Commission finds that both the policies and procedures that permitted a man in Hudson's medical state to be responsible for the operation of a freight train on the CN main line to be unacceptable.
Another frequently ignored safety regulation mentioned in the report was the "deadman's pedal", which a locomotive engineer had to keep depressed for the train to remain underway. Were he to fall asleep or pass out, his foot would slip from the pedal, triggering an alarm and engaging the train's brakes automatically a few seconds later. However, many engineers found this tiresome and bypassed the pedal by placing a heavy weight (often a worn out brake shoe) on it. It was uncertain whether the pedal had been bypassed in this case because the lead locomotive of the train had been destroyed. A more advanced safety device was available, the Reset Safety Control (RSC), required crew members to take an action such as pushing a button at regular intervals, or else automatic braking would occur, but neither lead locomotive was equipped with this safety feature. While the second locomotive in the freight train was equipped with RSC, it was not assigned as the lead locomotive because it lacked a "comfort cab". Management and union practice was to place more comfortable locomotives at the front of trains, even at the expense of safety.
The report also noted that although the front-end and rear-end crews should have been in regular communication, that did not appear to be the case in this accident. As the freight train reached Hargwen, Hudson radioed back to Smith that the signals were green, a communication that was heard by a following freight. As it ran towards Dalehurst there was no evidence of further communication. As the conductor is in charge of the train, had Smith felt that the train was out of control or there were serious problems, he should have pulled the brake cord in the caboose to stop the train. However, Smith, who appeared to be nervous while testifying, said that he did not feel that the freight was ever out of control, misjudging its speed. He also testified that he attempted to radio Hudson on two radios and several channels, but neither seemed to be working, despite the fact that immediately after the crash Smith was able to contact the dispatcher by radio. Even if Smith's testimony was true, he apparently did not consider the problem sufficiently serious to stop the train, a second misjudgment.
Read more about this topic: Hinton Train Collision