Euclid The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so."
The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so."
I read the transcript of the conversations and didn't get the impression that he was over-ruled.
Norm
Euclid NorthWest Guys, I think it is important to note that GE -7 locomotives are known for excessive smoke when loading and throwing oil out the stack (and causing turbo fires) so this may have been considered somewhat of a routine occurrence by those involved, especially due to the age of these units. Catch points ( I think known here as split rail derails) have been standard in the UK almost from the beginning, although IIRC not in dark territory (there was/is little). The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so." MM&A has a rule that calls for a response to engine symptoms. That rule would certaily not regard the condition as being routine as the symptoms manifested approaching Nantes. Maybe the day before when just moderately excessive smoke was seen, the condition might have been considered close to normal, but most certainly not when he arrived at Nantes.
NorthWest Guys, I think it is important to note that GE -7 locomotives are known for excessive smoke when loading and throwing oil out the stack (and causing turbo fires) so this may have been considered somewhat of a routine occurrence by those involved, especially due to the age of these units. Catch points ( I think known here as split rail derails) have been standard in the UK almost from the beginning, although IIRC not in dark territory (there was/is little).
Guys, I think it is important to note that GE -7 locomotives are known for excessive smoke when loading and throwing oil out the stack (and causing turbo fires) so this may have been considered somewhat of a routine occurrence by those involved, especially due to the age of these units.
Catch points ( I think known here as split rail derails) have been standard in the UK almost from the beginning, although IIRC not in dark territory (there was/is little).
MM&A has a rule that calls for a response to engine symptoms. That rule would certaily not regard the condition as being routine as the symptoms manifested approaching Nantes. Maybe the day before when just moderately excessive smoke was seen, the condition might have been considered close to normal, but most certainly not when he arrived at Nantes.
The LE then contacted the RTC in Bangor, Maine, who controlled movements of United States crews east of Megantic. During this conversation, the LE indicated that the lead locomotive had continued to experience mechanical difficulties throughout the trip and that excessive black and white smoke was now coming from its smoke stack. The LE expected that the condition would settle on its own. It was mutually agreed to leave the train as it was and that performance issues would be dealt with in the morning.
A taxi was called to transport the LE to a local hotel. When the taxi arrived to pick up the LE at about 2330, the taxi driver noted the smoke and mentioned that oil droplets from the locomotive were landing on the taxi’s windshield. The driver questioned whether the locomotive should be left in this condition. The LE indicated that he had informed MMA about the locomotive’s condition, and it had been agreed upon to leave it that way. The LE was then taken to the hotel in Lac-Mégantic and reported off-duty.
(Bolding mine)
From the TSB Summary….sounds like the engineer and the dispatcher both agreed the smoking was not that big of an issue.
Older GEs carbon up their exhaust manifold and stack, and can have spectacular exhaust stack fires…unburnt fuel can hit the glowing carbon and boom!
Ya can do S’mores on em if you’re brave enough.
23 17 46 11
Norm48327 Euclid The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so." I read the transcript of the conversations and didn't get the impression that he was over-ruled.
In the transcript, the point comes up when he is first told that the engine caught fire after he had left. I can't remember quite what he said, but it struck me as surprise and some comment about an earlier communication he had about somebody who told him it would be okay to leave it run.
I am not sure if or where it comes up in the accident report. But also, in the news coverage reported last year regarding his conversation with the taxi driver, he told the driver that he did not feel comfortable leaving the unit running, and he said he indended to re-contact the company and ask if they would reconsider their instruction to leave it running.
But now I am curious about exactly what the transcript of the phone conversations with RJ say. I will see if I can find it. There are several of those transcripts on line, and some are heavily edited. There are also maybe 6-8 different phone conversations, each with a transcript. However some of the trainscripts are not censored for salty exclamation, so I guess we can't link to them here.
Well, if the taxi driver said the engineer told him............ That sounds like hearsay evidence so I wouldn't be accepting it as fact.
Euclid Norm48327 Euclid The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so." I read the transcript of the conversations and didn't get the impression that he was over-ruled. In the transcript, the point comes up when he is first told that the engine caught fire after he had left. I can't remember quite what he said, but it struck me as surprise and some comment about an earlier communication he had about somebody who told him it would be okay to leave it run. I am not sure if or where it comes up in the accident report. But also, in the news coverage reported last year regarding his conversation with the taxi driver, he told the driver that he did not feel comfortable leaving the unit running, and he said he indended to re-contact the company and ask if they would reconsider their instruction to leave it running. But now I am curious about exactly what the transcript of the phone conversations with RJ say. I will see if I can find it. There are several of those transcripts on line, and some are heavily edited. There are also maybe 6-8 different phone conversations, each with a transcript. However some of the trainscripts are not censored for salty exclamation, so I guess we can't link to them here.
http://www.cbc.ca/news/canada/montreal/lac-m%C3%A9gantic-train-engineer-s-emergency-calls-released-1.2743201
RTC: No, no. I’m all set Tom, tied down at Nantes, just get me a yell when you’re off time.
TH: OK, I just thought I’d mention to you there, Glen, uh, the 5017, I worked her pretty damn hard coming up here. She’s smoking excessively now. I know it’s going to settle down once she cools down and stuff like that. I don’t know how good it’s going be on the eastbound now. When I left Farnham, I had engine hunting [sic] on it, I got it to settle down when I started using the seventh notch only, and it pulled real nice, and this last little pull here from the bottom of the hill at 26, down at Scotstown, all the way up to here, she worked pretty damn hard. Once I got stopped here, I only noticed when I got stopped here, that she was smoking excessively both black for a minute or so, and then she’d go white for a little bit, and then go back to black again.
RTC: Well you probably cleaned her out, Tom. This is Dave.
TH: Oh, this is Dave. OK, yeah. Could be I cleaned her out ... I’ve been here, you know, for 10 minutes. The smoke has cleared. Well, I should say there’s less smoke coming out of it right now. It’s still changing colour back and forth, black and white, black and white, a little bit there, but, maybe if she sits here for another hour or so, she will cool right down.
RTC: Well, that’s all we can do, Tom. We’ll check it in the morning and see what she says and see what she comes up with. Diagnose her then, I guess. Over.
TH: OK, I understand. I understand. What time is the eastbound engineer ready to go tomorrow?
The part I bolded deals with GEs getting a lot of carbon build up in the manifold and stack, running them hard often “cleans them out” by blowing most of the carbon build up out, what is left smokes for a while till it cools off.
Don’t see where Harding was harassed or intimidated or cajoled into leaving the locomotives as they were, it seems more along the lines of he and the RTC agreeing it would works itself out in time.
edblysard Ya can do S’mores on em if you’re brave enough.
Partial transcript from “Third conversation” in this link. You can listen by pressing the button for that conversation:
http://www.theglobeandmail.com/news/national/dispatches-from-a-disaster/article20148699/
RJ: Which one did you keep running?
TH: 5017.
RJ: The leader?
TH: Yes.
RJ: Ok, apparently it’s – it went on fire
TH: It went on fire?
RJ: Yeah.
TH: Oh, really?
TH: Okay [laughs]. I had problems with that. I reported it to Dave. Have you talked to Dave?
RJ: No.
TH: Okay. I told Dave that I worked it hard coming up there and she was smoking pretty good when I left her.
RJ: Okay.
TH: Now you’re telling me she caught on fire?
RJ: Yeah, she caught on fire.
I would not say that there was strong disagreement over the issue of whether to leave the engine running, but in the recording, I sense it might have been Dave who told him it would be okay to leave it run. It is not really stated, but seems to reside in the laugh when Harding finds out that the engine caught fire. Obviously it was not okay to leave the engine running.
But I suppose it is also fair to say that they mutually agreed to leave the engine running. It sounds to me like RTC was offering consolation that running hard on the approach to Nantes and smoking excessively did some good by blowing out the oil and carbon, and therefore it would be okay to leave it running under the assumption that there was no serious problem. And Harding seemed to accept that consolation. But obviously, it was not a case of simply fixing the problem by blowing out excess oil and carbon such as might accumulate from lower power conditions over a long period of time.
In any case, I do know that there is a quote in one of the newspaper articles in which Harding tells the cab driver that he feels uncomfortable leaving the engine running in that condition, and that he intended to ask the company to reconsider it when he got to Lac Megantic. I don’t know if he ever did ask them to reconsider it.
Overall, my only point about this is that this was not considered to be a routine smoke emission and stack torching incident typical of GE locomotives. The engineer had trouble loading the engine for much of the trip to Nantes.
You are reading something into the transcript that isn't there. Saying the engine worked hard does not constitute trepidations about leaving it running. Take the transcript as published in the TSB report as fact. Anything more is speculation.
Norm48327You are reading something into the transcript that isn't there. Saying the engine worked hard does not constitute trepidations about leaving it running. Take the transcript as published in the TSB report as fact. Anything more is speculation.
Norm,
You say that saying the engine worked hard does not constitute trepidations about leaving it running. Who ever said it did?
I am not sure what point you are making in seeming to disagree with me. Here is what I am saying: Some here have expressed the opinion that that it was bad judgment to leave a malfunctioning locomotive running to perform the critical function of pumping air. Then others who disagree with that conclusion say that people on the outside fail to realize that locomotives spew smoke and leak oil all the time, and so those outsiders are overreacting to what insiders regard as normal. So by extension, they conclude that nobody at MM&A should be criticized for leaving the locomotive running.
I simply disagree with that position. MM&A deserves lots of criticism for leaving the engine running. They had enough symptoms to clearly realize that this was not just some normal old locomotive behavior. This was going on for two days. The engine was smoking excessively, surging, and failing to fully load. Heavy black smoke was alternating with heavy white smoke. They reported the problem to the shop on the previous day, and again on the day the doomed oil train ran to Nantes. But they left the engine in service.
MMA’s Safety Rule 9126 stated:
When there is an abnormal condition such as noise, smoke or odor coming from engine, the engine should be shut down. Employees must immediately leave the engine room and shut down the engine by emergency “shut down” button at the control stand, control panel or fueling location on either side of the locomotive.
Notice the rule does not say that an abnormal condition such as smoke or odor coming from an engine should just be ignored because that is just what these old locomotives to.
Also, if you read the entire accident report, you will find this section: “2.4 Locomotive fire on MMA-002”
In that section it says this:
“As the condition worsened, the engine began to surge, which was reported during the previous trip by another LE, and again by the accident LE when departing Farnham. Despite these reports, MMA did not immediately address the situation, either by removing the locomotive from service or by taking it out of the lead position.
As the train worked up the grade toward Nantes, oil that was flowing from the damaged cylinder into the intake and exhaust manifold began to accumulate in the body of the turbocharger. There, it became superheated, creating the excessive black and white smoke observed by the LE.
The LE secured the train at Nantes and shut down all of the locomotives except the lead locomotive, including those with an auto-start system. The LE then had a discussion with the Bangor RTC, which did not resolve the situation. Despite MMA’s safety rule regarding actions to be taken in the event of abnormal engine conditions, as well as the observed excessive smoke and significant mechanical problems, it was decided that no immediate remedial action was necessary. It was agreed that MMA 5017 would be assessed in the morning to address the engine performance issue, and the lead locomotive was left running.
EuclidI am not sure what point you are making in seeming to disagree with me. Here is what I am saying: Some here have expressed the opinion that that it was bad judgment to leave a malfunctioning locomotive running to perform the critical function of pumping air. Then others who disagree with that conclusion say that people on the outside fail to realize that locomotives spew smoke and leak oil all the time, and so those outsiders are overreacting to what insiders regard as normal. So by extension, they conclude that nobody at MM&A should be criticized for leaving the locomotive running.
My point is that C30-7s are known for smoke, and shutting them down whenever they emitted smoke (very often, due to turbocharger lag) would be far too common an occurrence. MMA employees thus became complacent, believing this to be similar to regular smoke incidents. I am of the opinion that choosing a different unit to leave running would have been a much better choice that night, especially since there was white smoke, not the black un-combusted diesel that is normal. This indicates a bigger problem, and should have been addressed by shutting down the unit. Sadly, this was not the case.
Just so everybody is clear, when the following rule talks about an "engine" they are talking about the diesel prime mover located in the hood of the locomotive (note the use of the term "engine" used with "engine room" and the term "locomotive" used separately). They are not talking about exhaust from the stack, they are talking about ABNORMAL noise, smoke or odor from the motor. I did not read anyplace that the LE ever opened the hood doors and inspected the engine.
Dave H. Painted side goes up. My website : wnbranch.com
As a retired professional railroader, I have read the many posts and the report by the TSB.
I conclude that the MMA had a culture of let's get things done quickly without addressing the root causes of the problems, One example is the lowering of the speed to 10 MPH instead of repairing the track.
The locomotive shop involved should not have released the lead locomotive with slip-shod repairing.
Forget Ricky Gates and that mess. What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)?
Ed Burns of Anoka, MN
NP EddieForget Ricky Gates and that mess. What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)?
It will be an 'interesting' trial. Given the attendant development of a class-action suit (from Lac Megantic residents) associated with this wreck there will be court room drama....Canadian style (meaning likely pretty dry but very informative nevertheless). This is quite likely to be a protracted legal and court process......
Charlie
Chilliwack, BC
NP Eddie As a retired professional railroader, I have read the many posts and the report by the TSB. I conclude that the MMA had a culture of let's get things done quickly without addressing the root causes of the problems, One example is the lowering of the speed to 10 MPH instead of repairing the track. The locomotive shop involved should not have released the lead locomotive with slip-shod repairing. What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)? Ed Burns of Anoka, MN
What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)?
Criminally charging only the engineer and two supervisors seems too tightly focused to match the crime. The report makes it clear that the company had a deficient safety culture that goes right to the performance of the engineer in securing the train. With everything that was at stake in tying down the oil train above Lac Megantic, you don’t just give a guy a rule book and tell him to do the job.
Euclid NP Eddie As a retired professional railroader, I have read the many posts and the report by the TSB. I conclude that the MMA had a culture of let's get things done quickly without addressing the root causes of the problems, One example is the lowering of the speed to 10 MPH instead of repairing the track. The locomotive shop involved should not have released the lead locomotive with slip-shod repairing. What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)? Ed Burns of Anoka, MN Criminally charging only the engineer and two supervisors seems too tightly focused to match the crime. The report makes it clear that the company had a deficient safety culture that goes right to the performance of the engineer in securing the train. With everything that was at stake in tying down the oil train above Lac Megantic, you don’t just give a guy a rule book and tell him to do the job.
Do you really think the MMA is the only shortline to lower track speeds until the millions of dollars are available to rehab the track ?
Is what your saying that every shortline or class one that chooses to forgo expensive track projects on low volume lines is criminally negligent?
Do you not think that every shortline finds the cheapest way to get things done?
Attitudes like this will make the short line's and regionals go away.
And yes Bucky.. the railroads hand the employees a rulebook ,test them on their knowledge and tell them to do their jobs. The engineer on this train was NOT a rookie and was primarily trained by CP rail. We can test them, berate them, browbeat them and fire them. The bottom line is that if we can't trust them to do their job and obey the rules we may as well scrap the rail industry.
"Lack of safety culture" that phrase is becoming over used these days and could mean many things depending on the persons motives. Its all BS.
Randy Stahl Euclid NP Eddie As a retired professional railroader, I have read the many posts and the report by the TSB. I conclude that the MMA had a culture of let's get things done quickly without addressing the root causes of the problems, One example is the lowering of the speed to 10 MPH instead of repairing the track. The locomotive shop involved should not have released the lead locomotive with slip-shod repairing. What will the Canadian court system do with the three MMA employees involved in the wreck seeing they were acting as agents for the MMA (keeping in mind the lack of safety culture)? Ed Burns of Anoka, MN Criminally charging only the engineer and two supervisors seems too tightly focused to match the crime. The report makes it clear that the company had a deficient safety culture that goes right to the performance of the engineer in securing the train. With everything that was at stake in tying down the oil train above Lac Megantic, you don’t just give a guy a rule book and tell him to do the job. Do you really think the MMA is the only shortline to lower track speeds until the millions of dollars are available to rehab the track ? Is what your saying that every shortline or class one that chooses to forgo expensive track projects on low volume lines is criminally negligent? Do you not think that every shortline finds the cheapest way to get things done? Attitudes like this will make the short line's and regionals go away. And yes Bucky.. the railroads hand the employees a rulebook ,test them on their knowledge and tell them to do their jobs. The engineer on this train was NOT a rookie and was primarily trained by CP rail. We can test them, berate them, browbeat them and fire them. The bottom line is that if we can't trust them to do their job and obey the rules we may as well scrap the rail industry. "Lack of safety culture" that phrase is becoming over used these days and could mean many things depending on the persons motives. Its all BS.
While the LE was a long term trained and qualified Engineer. The change to single person operation added on responsibilities of the now non-existent Conductor on this individual. There is a difference in knowing how to answer questions on a rules examination test and properly applying those rules in the real world of the field. The TSB report highlighted that the LE had successfully passed his rules examinations but had never had any specific instruction as to what Conductor responsibilities he would have to assume in the single person operation. This doesn't excuse his actions, however, it may explain them. He had never been taught what proper securement of a train was and felt that hand brakes on the locomotive consist and one car complied with the 10% portion of the rule; he also felt that having the independent brake applied was a proper part of the securement. In both cases he was wrong. The report does not make any assertions as to the efficiency testing of MMA on compliance with securement rules, and the numbers of tests and failures.
As a industry we must trust that employees will perform their jobs correctly, however, they need to be periodically tested to ensure proper compliance. The biggest problem is that the TESTER's must also know what the CORRECT procedure. From Ed Burkhart's pronouncements at the time of the incident, I am not so sure the MMA officials knew what the CORRECT securement procedure was.
Never too old to have a happy childhood!
BaltACDAs a industry we must trust that employees will perform their jobs correctly, however, they need to be periodically tested to ensure proper compliance. The biggest problem is that the TESTER's must also know what the CORRECT procedure. From Ed Burkhart's pronouncements at the time of the incident, I am not so sure the MMA officials knew what the CORRECT securement procedure was.
And this goes back to my assertion that pretty much everyone assumed that they, and everyone else involved, were taking the right actions, based on what they knew at the time.
And we all know what happens when you assume...
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...
dehusman Just so everybody is clear, when the following rule talks about an "engine" they are talking about the diesel prime mover located in the hood of the locomotive (note the use of the term "engine" used with "engine room" and the term "locomotive" used separately). They are not talking about exhaust from the stack, they are talking about ABNORMAL noise, smoke or odor from the motor. I did not read anyplace that the LE ever opened the hood doors and inspected the engine. MMA’s Safety Rule 9126 stated: When there is an abnormal condition such as noise, smoke or odor coming from engine, the engine should be shut down. Employees must immediately leave the engine room and shut down the engine by emergency “shut down” button at the control stand, control panel or fueling location on either side of the locomotive.
So you are saying that when the MM&A rule refers to abnormal “smoke from the engine,” that does NOT include the smoke from the exhaust. How do you arrive at the conclusion that excessive exhaust smoke is not “smoke from the engine?” Exhaust smoke is a classic way to diagnose engine problems.
You reinforce your argument by saying that the report does not say that the engineer ever opened an engine hood door. Well if he didn’t, maybe he should have.
Your points on this matter here and in other posts seem intent on the premise that there was nothing out of the ordinary that should have alerted the engineer to the problem. And it makes no difference to you that the engineer and the previous engineer described having an engine problem, and reported the problem to the company in detail.
Obviously, there was a serious problem because it ultimately led to an engine fire. I am at a loss to understand why you insist on assuming that the locomotive exhibited no symptoms that were abnormal.
Bucky,
Show me an old GE that hasn't 'wet-stacked' and spit oil, smoked, of shown flame out the exhaust and I'll show you one that isn't running.
That is beside the point that I am making. What exactly is the point that you are making? Are you trying to say that the symptoms did not indicate anything abnormal? If you are, the TSB report disagrees with you. Also the engineer Tom Harding disagrees with you. And the previous engineer to run that engine disagrees with you.
Euclid Obviously, there was a serious problem because it ultimately led to an engine fire. I am at a loss to understand why you insist on assuming that the locomotive exhibited no symptoms that were abnormal.
Norm48327Show me an old GE that hasn't 'wet-stacked' and spit oil, smoked, of shown flame out the exhaust and I'll show you one that isn't running.
It's been discussed here before:
http://cs.trains.com/trn/f/741/t/145041.aspx
ALCOs are pretty good at coating everything around them with oil droplets if they idle too long. Been there, done that.
dehusmanThe real question is how did things get so bad that the performance of the locomotive and the engineer was allowed to be "normal"?
C&NW, CA&E, MILW, CGW and IC fan
Euclid Norm, That is beside the point that I am making. What exactly is the point that you are making? Are you trying to say that the symptoms did not indicate anything abnormal? If you are, the TSB report disagrees with you. Also the engineer Tom Harding disagrees with you. And the previous engineer to run that engine disagrees with you.
Neither you nor I were there so I'll take your reply for what it's worth. I was just pointing out it's normal for older GE's to spit oil into the stack and beyond.
One thing to remember about Short Line power - for the most part all of it started out in major Class 1 service and remained in that service until it got to the point where it's economic return was worse than the economic costs of keeping it in repair. So 'new' short line power comes to them worn out and all the short lines do is add more wear with minimal repairs to keep the locomotive in service.
BaltACD One thing to remember about Short Line power - for the most part all of it started out in major Class 1 service and remained in that service until it got to the point where it's economic return was worse than the economic costs of keeping it in repair. So 'new' short line power comes to them worn out and all the short lines do is add more wear with minimal repairs to keep the locomotive in service.
I sure think we are seeing that in this case.
Also----
From the report:
Item 3.0 Findings
3.1 Findings as to causes and contributing factors
Number 4 of Findings as to causes and contributing factors:
“Despite significant indications of mechanical problems with the lead locomotive, the locomotive engineer and the Bangor, Maine, rail traffic controller agreed that no immediate remedial action was necessary, and the locomotive was left running to maintain air pressure on the train.”
It sounds like TSB of Canada feels that the company committed a rules violation when their LE and RTC determined that there was no reason to react to the "significant indications of mechanical problems."
Euclid Number 4 of Findings as to causes and contributing factors: “Despite significant indications of mechanical problems with the lead locomotive, the locomotive engineer and the Bangor, Maine, rail traffic controller agreed that no immediate remedial action was necessary, and the locomotive was left running to maintain air pressure on the train.” It sounds like TSB of Canada feels that the company committed a rules violation when their LE and RTC determined that there was no reason to react to the "significant indications of mechanical problems."
As it turned out, the oil leak was far from "routine" according to the report:
"It was determined that the cam bearing had fractured when the mounting bolt was over-tightened after the cam bearing had been installed as part of a non-standard repair to the engine block. This temporary repair had been performed using a polymeric material, which did not have the strength and durability required for this use
"Failure of the cam bearing reduced the engine oil supply to the valve train at the top of the associated power assembly. The decreased lubrication led to valve damage and eventually to a punctured piston crown. The damaged valves and piston crown allowed engine oil to flow into the cylinder and the intake and exhaust manifolds. Some of the engine oil collected in the body of the turbocharger. The engine fire later occurred in the exhaust stack due to the build-up and ignition of engine oil in the body of the turbocharger."
"In a system where the final layer of defence is reliance on the application of hand brakes and an effectiveness test, there needs to be clear rules that are well understood and consistently applied. However, no matter how clear and comprehensive rules are, these are administrative defences and, invariably, there will be instances where practices in the field will deviate from these written rules and procedures. TSB investigations into the Lac-Mégantic accident and other runaways have revealed that the chain of events almost always included the application of an insufficient number of hand brakes to secure the train. This means that no matter how well the rule is worded, it will not always be strictly complied with, thereby introducing vulnerability into the safety system. The following TSB data suggest that these vulnerabilities are magnified at short line railways. Of 16 investigations involving short line railways in the past 20 years (including 6 runaways), deficiencies in rules compliance, misinterpretation and/or training have been identified as causal or contributing in 10 cases (62%)."
"However, although the impact statement specifies that audits would verify the effectiveness of a company’s SMS, it is not clear how this would be carried out or whether the baseline audit would examine the effectiveness of all components of a company’s SMS.
"The success of this new approach in improving safety will depend on 2 factors. First, railways are rule-based cultures, and the full transition to SMS will require a cultural shift away from strict reliance on rules, to a culture that recognizes that administrative defences alone are not sufficient to maintain safe operations and that seeks to build multiple layers of defence to reduce risks.
"Secondly, TC now has a legal and conceptual framework to require SMS implementation, but equally important is how the regulator uses these tools and what action it takes in the coming years. It is crucial that TC follow up on its commitments relating to SMS audits, and on truly ensuring that railways have an SMS in place that is capable of identifying risks and managing them to prevent accidents.
Until Canada’s railways make the cultural shift to SMS, and TC makes sure that they have effectively implemented SMS, the safety benefits from SMS will not be realized."
dehusman My opinion is culture of dealing with marginal equipment and conditions on a daily basis led him to an environment were "abnormal" was a pretty high bar. Right or wrong, for that engineer, at that point in time, the conditions of the locomotive did not meet the threshold of "abnormal".
+1. And I think that the answer to your question is "lack of money".
White smoke indicates that oil is burning, as diesel burns black. Neither the engineer or dispatcher knew this, or the locomotive would have been shut down. Oil is a very finite supply and would have been burned off far before morning, shutting down the unit and seizing the prime mover. So, regardless of the fire department's shutting down of the locomotive, a runaway would have probably occurred had the unit been left, it just might have taken longer.
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