Here is the link to the TSB report on the Lac Megantic wreck:
http://www.tsb.gc.ca/eng/rapports-reports/rail/2013/r13d0054/r13d0054.asp
There is also a report in today's TRAINS Newswire.
Bruce
So shovel the coal, let this rattler roll.
"A Train is a Place Going Somewhere" CP Rail Public Timetable
"O. S. Irricana"
. . . __ . ______
Bruce, thank you for posting this report.
Johnny
Interesting reading - but long.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
Very interesting. Didnt read it all, but these documents offer insights into the operations of railroads...particularly when things go bad.
ed
tree68 Interesting reading - but long.
I read much of it. The fire department was cleared of any error.
C&NW, CA&E, MILW, CGW and IC fan
Hi All
What a report!
Just skimmed through it.
Railways and regulators both really get a thorough going over re operating procedures/enforcement, maintenance standards and oversight (both mechanical and ROW).
Looks like there's plenty of responsibility to be taken by MMA, TC and the oil companies at source.
Charlie
Chilliwack, BC
Yesterday's News Wire story had the chairwoman of the safety board saying 18 factors contributed to the tragedy -- " ... and you take any one of them away, and this might not have happened."
The fatal combination of circumstances might never be replicated. Something to remember before we hamstring oil by rail with too many perfect-world safeguards, and on a breathless timetable.
For instance: Given the forces involved in that 65-mph derailment in the heart of downtown, would it really have made any difference what kind of tank cars the oil was riding in?
We have had a lot of discussion about the role of the automatic brake and how it might have been inadvertently released. It is interesting to learn now that when the engineer left the train standing at Nantes, he left the automatic air brake fully released.
While the FD did what they were supposed to to under the circumstance of the engine fire; shutting down the lead engine, which controlled the independent locomotive brake, thus allowing the pressure in the independent system to leak off, thus releasing the bulk of the braking power on the locomotive consist (which had hand brakes applied - but locomotive hand brakes are not effective on all wheels of the locomotive) is the causitive factor that exposed the fact that the Engineer did not adequeately secure his train.
Never too old to have a happy childhood!
BaltACD While the FD did what they were supposed to to under the circumstance of the engine fire; shutting down the lead engine, which controlled the independent locomotive brake, thus allowing the pressure in the independent system to leak off, thus releasing the bulk of the braking power on the locomotive consist (which had hand brakes applied - but locomotive hand brakes are not effective on all wheels of the locomotive) is the causitive factor that exposed the fact that the Engineer did not adequeately secure his train.
Too obvious
schlimm BaltACD While the FD did what they were supposed to to under the circumstance of the engine fire; shutting down the lead engine, which controlled the independent locomotive brake, thus allowing the pressure in the independent system to leak off, thus releasing the bulk of the braking power on the locomotive consist (which had hand brakes applied - but locomotive hand brakes are not effective on all wheels of the locomotive) is the causitive factor that exposed the fact that the Engineer did not adequeately secure his train. Not the causative factor. There was an employee from MMA present at the time who was aware of the FD shutting down the faulty and burning lead engine. He could have done something, such as starting another unit to maintain braking power or applying more hand brakes on trailing cars, but he chose not to. 6. When the locomotive was shut down as a response to the engine fire, no other locomotive was started, and consequently, no air pressure was provided to the independent brakes. Further, locomotives with an auto-start system were shut down and not available to provide air pressure when the air brake system began to leak.
The report stated that the MMA employee that responded was a MofW employee. A employee that is not trained on the operations of locomotives or their braking systems. The report also states that a 'proper party' (my term) had a attempt made to notify them, they did not answer or respond.
While I know how air brakes work, I guess I don't know the more technical details as well as I thought.
The report said the brake pipe reduced at an average rate of 1 psi/minute and the cars didn't set up. (According to the time line from the event recorder, the brake pipe dropped 15 psi in 8 minutes for a rate of 1.875 psi/min.) I know it only takes a 1 to 1.5 psi difference in pressure for the control valve to operate, but evidently it has to happen at a certain psi/minute rate. So what is the minimum psi/min rate it needs to "see" something is happening? What is the rate of a service reduction, say a 6 to 8 psi minimum initial set as made by the engr's brake valve?
Trying to find a good diagram of the control valve (informally aka, triple valve) during various phases has been hard. Most are very simplistic. I was always under the impression once charged the control valve was also in a lap position, no air moving through it like it is after a brake application. However, I've seen one diagram that shows a feed port still allowing air from the brake pipe to the auxiliary reservoir after fully charged. If this is so, does that mean that if the brake pipe reduces at 1 psi/min, the auxiliary reservoir also reduces at the same rate backwards through that port? If that's the case, then I could see there would be no pressure differential between the two sides of the control valve. It couldn't "see" a drop in brake pipe pressure no matter how much the brake pipe drops because the aux res also has been dropping.
I've read reference somewhere else from Canada where after fully securing the train with hand brakes, they would leave the automatic in release. In theory, if secured it shouldn't be a problem. (After all, you definitely aren't depending on air brakes to hold the train.) The problem comes when you get a false positive on the securement test. You think you have enough hand brakes set, but you don't.
Had he set 20 psi, it probably wouldn't have run away after the brake pipe leaked off. At least until the air leaked off individual brake cylinders and that could take a few days, if not longer. Of course that's through my understanding of how things work and I've been wrong before
Jeff
BaltACD schlimm BaltACD While the FD did what they were supposed to to under the circumstance of the engine fire; shutting down the lead engine, which controlled the independent locomotive brake, thus allowing the pressure in the independent system to leak off, thus releasing the bulk of the braking power on the locomotive consist (which had hand brakes applied - but locomotive hand brakes are not effective on all wheels of the locomotive) is the causitive factor that exposed the fact that the Engineer did not adequeately secure his train. Not the causative factor. There was an employee from MMA present at the time who was aware of the FD shutting down the faulty and burning lead engine. He could have done something, such as starting another unit to maintain braking power or applying more hand brakes on trailing cars, but he chose not to. 6. When the locomotive was shut down as a response to the engine fire, no other locomotive was started, and consequently, no air pressure was provided to the independent brakes. Further, locomotives with an auto-start system were shut down and not available to provide air pressure when the air brake system began to leak. The report stated that the MMA employee that responded was a MofW employee. A employee that is not trained on the operations of locomotives or their braking systems. The report also states that a 'proper party' (my term) had a attempt made to notify them, they did not answer or respond.
I have trouble with the term that "he chose not to"... there are an awful lot of things that I didn't do today, but that is not necessarily because I "chose not to", but more because they never occurred to me that I might do them... I merely didn't do them.
Semper Vaporo
Pkgs.
As pointed out before, any one of the coincidences taken out of the loop and we would not have anything to discuss.
As I pointed out in another thread, the management failed too, in that they didn’t not perform the required testing, in the required manner, to make sure their employees were aware of how to apply the rules they work under, and to make sure their employees were following those same rules,
While that alone does not absolve the engineer of securing his train, it explains, or partially explains why he did it the way he did, and that this was the “normal” procedure with this train at that location.
Fred,
You are correct, other than using the canisters designed to haul spent nuclear fuel rods, not much would have survived those forces unscathed and intact.
As a working railroader, I am disappointed in the engineer, had he done a proper handbrake test, all those folks would be alive, and securement would not be an issue.
I am also angry at the management, they had a duty to train their guys, and test their guys as an ongoing process to run a safe operation…I had my one on one safety briefing last week on my carrier, and out of 93 test done over a 6 month period, I failed zero….it’s not that hard to follow the rules, and if the employees know they are being tested at random, they tend to follow the rules.
One test, just one failure, and I bet this engineer would have done a proper test, and secured the train right.
23 17 46 11
Semper Vaporo BaltACD schlimm BaltACD While the FD did what they were supposed to to under the circumstance of the engine fire; shutting down the lead engine, which controlled the independent locomotive brake, thus allowing the pressure in the independent system to leak off, thus releasing the bulk of the braking power on the locomotive consist (which had hand brakes applied - but locomotive hand brakes are not effective on all wheels of the locomotive) is the causitive factor that exposed the fact that the Engineer did not adequeately secure his train. Not the causative factor. There was an employee from MMA present at the time who was aware of the FD shutting down the faulty and burning lead engine. He could have done something, such as starting another unit to maintain braking power or applying more hand brakes on trailing cars, but he chose not to. 6. When the locomotive was shut down as a response to the engine fire, no other locomotive was started, and consequently, no air pressure was provided to the independent brakes. Further, locomotives with an auto-start system were shut down and not available to provide air pressure when the air brake system began to leak. The report stated that the MMA employee that responded was a MofW employee. A employee that is not trained on the operations of locomotives or their braking systems. The report also states that a 'proper party' (my term) had a attempt made to notify them, they did not answer or respond. I have trouble with the term that "he chose not to"... there are an awful lot of things that I didn't do today, but that is not necessarily because I "chose not to", but more because they never occurred to me that I might do them... I merely didn't do them.
He 'chose' not to because he had no training on how to do any of the things you think he should have done. Just because he drew a paycheck from MMA did not qualify him for ALL job functions that MMA employees perform.
Starting a railroad locomotive is not turning the ignition key in your Kia. There are certain procedures that must be performed, both inside the cab and inside the engine room of the locomotive.
schlimmThere was an employee from MMA present at the time who was aware of the FD shutting down the faulty and burning lead engine. He could have done something, such as starting another unit to maintain braking power or applying more hand brakes on trailing cars ...,
The report itself takes some pains to establish that the employee in question did not know the specific locomotive- or train-related details. There were attempts to contact an employee who did have locomotive-related knowledge, but in the time available no one was able to contact him.
As it turns out, I have been able to confirm that the employee in question indeed was "simply NOT trained on train operation". While it is possible that he could have been coached through some of the steps of starting a unit, checking brake application, or even dumping the air, the people who could have walked him through the procedures had already ordered him not to do anything. Remember that at that point most of the people involved were of the understanding (very wrongly, as it turned out) that the train itself had been secured adequately in a way that a non-running consist would not affect.
edblysard...and if the employees know they are being tested at random, they tend to follow the rules.
I'm dealing with that right now (but not regarding a runaway train).
While there's no question that the train was improperly secured, the engineer fell into the "it's always worked before" trap. I'm sure he left the train satisfied that he had adequately secured it. I can't think of a single reason he wouldn't believe that, or that he'd leave the train thinking "close enough."
The engineer in question had run that route dozens of time, and had probably parked trains in that very spot many times as well. As Ed suggests, management screwed up by not double-checking his work. It's possible that if the engineer had set "10% + 1" - maybe six or seven of the tank cars plus the locomotives, caboose, and buffer car, that everything would have stayed put, even if he was relying on the independent to pass the hold test.
At the very least, the tank cars with brakes set might have had a wheel failure and piled the train up out in the boonies, instead of in town.
But I'm wandering into conjecture. The facts are out and it's up to all concerned to learn from the mistakes.
I too wonder how much of the engineer’s actions were guided by a routine that was established at a higher level in the company. The engineer was said to be very well experienced, and reliable.
From what I have read, I gather that no push-pull test was performed. If an engineer were very well experienced, and reliable, why would he ignore the requirements of Rule 112?
That part suggests to me that the engineer had become accustomed to following a rationale that the test would only confirm what you already know. In other words, if you set some brakes and pass the test, since you know how many brakes that you set, you could simply set the same amount of brakes each time, and need not conduct any tests to confirm securement. From that point, everybody gets a little lazy and the next thing you know is that the handbrake setting effort has declined because nobody is working to satisfy a test.
I don’t understand how the engineer or his supervisors did not immediately recognize the peril of leaving the entire locomotive consist shut-down. They all know air brakes. They know that at least one engine running to pump air is necessary to preventing set air brakes from leaking off and releasing. They all knew that the only running locomotive unit had been shut down during the fire department phase. They should have known that the train would run away.
[This post was intended as a private message, and has been redirected accordingly.]
Euclid From what I have read, I gather that no push-pull test was performed. If an engineer were very well experienced, and reliable, why would he ignore the requirements of Rule 112?
There was a push pull test performed.
Read section 1.1, page two, top paragraph.
The LE performed a hand brake effectiveness test (whether he performed it well or correctly, he did perform a test, and the train passed the test he did perform).
I don’t understand how the engineer or his supervisors did not immediately recognize the peril of leaving the entire locomotive consist shut-down.
What is the peril? I don't understand why there is a peril.
They all know air brakes. They know that at least one engine running to pump air is necessary to preventing set air brakes from leaking off and releasing. They all knew that the only running locomotive unit had been shut down during the fire department phase. They should have known that the train would run away.
According to the TSB report the automatic brakes were RELEASED. Nobody was counting on the engines keeping the train brakes set because the air brakes were released on the train by the engineer when he did the hand brake test.
All of the engines had handbrakes set.
The LE told the RTC that the train had been properly secured.
Dave H. Painted side goes up. My website : wnbranch.com
The Mow employee may, or most likely, did not know that one of the locomotives had to be running to keep the brake system charged…its not something they would be familiar with, same way as I have no clue how to run a tamper..turn me lose with a rail saw and someone is going to be real sorry!
I to have issue with the “he chose not to” statement…odds are, he simply didn’t know to.
The MOW employee probably knew, or was told that the hand brakes were set and they will hold the train.
* I didn't read the whole report yet, it is long.
The entire incident is filled with assumptions on the part of the players.
The LE assumed that he had properly secured the train. This was undoubtedly based on his experience and the fact that it had always worked in the past.
The LE also assumed that the smoky locomotive wouldn't be an issue.
The RTC assumed that the train had been properly secured. He probably assumed that the "10%+1" rule had been abided by, so shutting down the locomotive wasn't an issue.
As Kyle points out, the MOW likely employee made the same assumption, although he probably wasn't aware of the specific requirements.
And the fire department assumed they had done the right thing by shutting down the locomotive, as it was IAW the instructions they had previously received.
Add them all up and we saw what happened.
We all make choices, as we are not robots. The track worker reported the situation to the RTC (who had operating experience) and was told nothing more needed to be done. He then had a choice. He could have followed orders, even if he had doubts. Or he could have chosen to request that an LE be sent to the scene, if he had any doubts as to the RTC's decision. He chose the former and no blame was attached to that choice.
deleted by OP
The LE was contacted at his hotel and he asked the RTC if they wanted him to go back to the train and start up one of the other locos. The RTC said no, that wouldn't be necessary. I think this was detailed in one of the Appendices which detailed the radio conversations regarding this event.
From what I understand, there was a second train tied up at Vachon, to the east of Lac Megantic, and that the LE's were to swap trains the next day and return to their home terminals. The LE of the loaded oil train was already off duty when the fire was extinguished, so calling him back would've restarted his rest and delayed the following day's operations. (My supposition, this was not specifically discussed in the report.)
Correct..
As a retired professional railroader, I must ask this question: What does then president Ed Burkhart have to say about this? The culture of safety begins from the president on down.
Ed Burns
Retired
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