Details of a disturbing incident involving an uncontrolled train that rolled downhill into a western Manitoba town more than a year ago have come to light — and one expert wonders why that information is only being released now.

A CP Rail train carrying more than 100 grain hoppers rolled uncontrolled and backward down a hill though the town of Minnedosa in January 2018.

The details are contained in a rail safety advisory — a letter from the Transportation Safety Board to Transport Canada notifying the agency of the incident. The advisory was released in full to CBC News late Friday and largely places blame for the incident on the train's crew and their decisions.

"In this occurrence, a number of operational actions and decisions were not consistent with regulatory requirements and railway standard operating procedures, much of which occurred in the presence of a company officer," the report read.

The safety board said the train was travelling up a hill near Minnedosa, a town about 200 kilometres west of Winnipeg just off of Highway 16, when the emergency brakes were applied shortly after 6 a.m. on Jan. 1, 2018.

The crew left the train and found a broken knuckle connector behind a car near the front of the train. The knuckle was changed, the train recoupled and the air brake system partially re-charged by 7:40 a.m., the report said.

However, the train still wouldn't move and the emergency brakes were applied again. A CP company officer arrived shortly after the second application to help the crew.

The report said the crew then only partially charged the train's air brake system before trying to move again. The train separated and the head-end locomotive made it about nine metres before the emergency brakes were applied once again.

Train rolls downhill

The crew got off and discovered another broken knuckle connector. While they were dealing with that situation, the train's engineer noticed the rest of the train rolling backward downhill.

"The locomotive engineer attempted unsuccessfully to catch up with (and couple onto) the uncontrolled portion of the train," the Transportation Safety Board said. "The 112 loaded covered hopper cars and the mid-train locomotive rolled uncontrolled for almost a mile."

The runaway cars moved down the hill at a speed of about 11 kilometres per hour and then through two road crossings — a passive crossing with signs, and an automatic crossing with flashing lights and bells — before coming to a stop in the town of Minnedosa.

The safety board said no emergency radio broadcasts were made — a requirement after emergency brake applications. Retainers and handbrakes were not applied — a requirement when someone isn't physically at the train's controls.

Minnedosa, Man., is located about 45 kilometres north of Brandon. (Riley Laychuk/CBC )

"The crew members believed that, as they were in close proximity to the train, the train was attended [and] in compliance with [federal regulations]," the TSB report read.

The report also found some of the crew's actions were not in compliance with CP's own operating procedures. Investigators analyzed the train's recorders and found it was placed into emergency mode 12 times in an apparent effort to get the locomotive to respond and move.

The move reduced available pressure in the air brake system, the safety board said.

Full investigation not done

The Transportation Safety Board investigated the incident, but didn't publicly release an investigation report.

A spokesperson told CBC News on Friday that the scope of the probe was simply data gathering and not a full investigation.

A spokesperson for CP Rail said the incident was a result of human error and that it took immediate action to educate its employees.

"Safety is an ongoing journey; it's not about a single destination," said CP Rail spokesperson Mallory McCredie.

"It's a foundational principle, engrained in everything we do, and we recognize that we must remain vigilant with these efforts and commitments to safety."

'It's not very transparent'

Ian Naish, a rail safety consultant and former director of rail and pipeline investigations at the Transportation Safety Board of Canada, believes the public should have been made aware of the incident sooner.

"It's not very transparent," he told CBC News by phone on Friday. "It was deemed serious enough that a safety advisory letter was sent out to Transport Canada, which kind of indicates there's an issue for sure."

He said a full investigation could help determine how to prevent future runaway incidents from happening in the future.

"It certainly doesn't give you a warm, fuzzy feeling when you know there are fairly heavy trains rolling through town at a fair rate of speed, I'd suspect," said Naish. "I think the public … deserve to know all the facts."

The safety board told Transport Canada that there were six operational issues identified in its probe, including the lack of radio broadcasts, improper train securement, issues surrounding the use of air brakes and hand brakes, and improper use of the throttle.

It's not clear if the employees involved in the incident were reprimanded as a result.