Final TSB Report on Lac Megantic Wreck

[BaltACD]

schlimm

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:

1.15.1

"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."

All of which was determined in the 'laboratory' after the incident.  The LE had no knowledge of the failures - just some smoke - smoke that he most likely has had on at least one engine in every locomotive consist he has operated for MMA.  ie.  nothing really out of the ordinary.  When you continually operate with less than optimum equipment, your standards change because you come to know what will get fixed and what won't.

[schlimm]

BaltACD

All of which was determined in the 'laboratory' after the incident.  The LE had no knowledge of the failures - just some smoke - smoke that he most likely has had on at least one engine in every locomotive consist he has operated for MMA.  ie.  nothing really out of the ordinary.  When you continually operate with less than optimum equipment, your standards change because you come to know what will get fixed and what won't.

Perhaps the LE needed more training.   The uniform standards need to be applied equally.  If shortlines (or Class Ones) cannot operate within those standards, then they should be forced to discontinue operations until such time as they can prove compliance.  That also appears to be a message of the report, that the Canadian regulators were also lax in enforcement.

The point of a report like this isn't to make excuses.  The point is to find out what went wrong and correct the contributing problems for the future.   Otherwise you have folks saying, in effect, "Oh well, stuff happens.  You can't expect perfection.  Too expensive."    As long as priority number one is maximizing profits over safety and service, you will get more of the same.

[Euclid]

Norm48327

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.

Norm,

I posted that it should have been obvious to an engineer that he had a serious engine problem, as indicated by abnormal symptoms.  Right after my post, you addressed a comment to me as follows:

“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.”

So I understood you to be refuting what I had just said in my original comment where I said that it should have been obvious to the engineer that he had an engine problem.  That was my interpretation because I had said that excess smoke and oil droplets were abnormal, and you said they are normal with older GE locomotives.  Thanks for now clarifying that your comment had no contextual relationship to my comment, but was simply an independent statement of fact. 

I also want to clarify something:

When I say it should have been obvious to the engineer that he had an engine problem, it is only to refute those who seem to believe that it would not have been obvious to the engineer.  So I am speaking to those who say that the symptoms were not abnormal; they were as insignificant as an oil spot in your driveway; all GE locomotive smoke and spit oil; the report does not say the engineer looked under the hood; hindsight is 20/20; etc, etc. 

But I don’t know why it should be necessary to push back against those arguments because the engineer OBVIOUSLY KNEW he had an engine problem.  He said the symptoms were abnormal.  The symptoms also included more than just excess smoke.  The excess smoke alternated from black to white, and the engine surged when under load.  The previous engineer on that locomotive observed and reported the same problem. 

[Norm48327]

He knew there was an engine problem. He also didn't think it necessitated shutting it down. That seems like an informed judgement call.

[Euclid]

Norm48327

He knew there was an engine problem. He also didn't think it necessitated shutting it down. That seems like an informed judgement call.

Norm,

An informed judgment call?  It was a rules violation.  But I do not know whose judgment call it was.  The engineers reported the problem to the company, so apparently the company decided to keep running the engine.  Maybe the engineers agreed with the decision; maybe they did not. 

But running the engine against the rules is an indication of a risk-taking culture that might attach to a shortline trying to make do with limited resources.   The risk in persisting with an ailing locomotive led to a fire, and then to finding the fatal flaw in the securement.  The fatal flaw in securement consisting of relying on air brakes was also a symptom of the same risk-taking culture.

[dehusman]

Euclid

But I don’t know why it should be necessary to push back against those arguments because the engineer OBVIOUSLY KNEW he had an engine problem.  He said the symptoms were abnormal.  The symptoms also included more than just excess smoke.  The excess smoke alternated from black to white, and the engine surged when under load.  The previous engineer on that locomotive observed and reported the same problem. 

The last sentence in your post is the most telling.

You are asking the wrong question about the wrong engineer.

The real question is why didn't the FIRST engineer shut down the locomotive.  If it was "OBVIOUS" that the engine was defective (as you yourself noted he had the same problems), then the engine should have been shut down by the first engineer.

Obviously it wasn't shut down and another leader put in its place.  Both engineers made the same decision when faced with the same set of circumstances in the same context.  Its highly probable that the actions of the first engineer influenced the actions of the second engineer.  The locomotive was acting up, but it made it "OK".  The first engineer tells that to the second engineer.  That creates an expectation in the second engineer that the engine will perform the same.  It will smoke and run rough, but will continue on.  Just another worn out, crappy engine.

Here's an excercise for you.  For the next month, as you drive to an from work, look at the cars and trucks around you.  How many of them have smoking tail pipes, how many have low air in the tires, how many have cracked windshields, how many have missing fenders or bumpers, how many are making lots of noises?  All of these people OBVIOUSLY KNOW they have a safety or mechanical defect in their car which could affect their personal safety and the safety of anybody who travels with them.  If you can see them, they can see them.  And yet day after day they will drive to their vehicles.  Not saying its right, just saying that once a person accepts a certain level of defects as "normal" those defects cease to be "defects" in their eyes.  It becomes SOP, just same sh*t, different day.  That's what causes accidents.

[BaltACD]

schlimm

BaltACD

All of which was determined in the 'laboratory' after the incident.  The LE had no knowledge of the failures - just some smoke - smoke that he most likely has had on at least one engine in every locomotive consist he has operated for MMA.  ie.  nothing really out of the ordinary.  When you continually operate with less than optimum equipment, your standards change because you come to know what will get fixed and what won't.

Perhaps the LE needed more training.   The uniform standards need to be applied equally.  If shortlines (or Class Ones) cannot operate within those standards, then they should be forced to discontinue operations until such time as they can prove compliance.  That also appears to be a message of the report, that the Canadian regulators were also lax in enforcement.

The point of a report like this isn't to make excuses.  The point is to find out what went wrong and correct the contributing problems for the future.   Otherwise you have folks saying, in effect, "Oh well, stuff happens.  You can't expect perfection.  Too expensive."    As long as priority number one is maximizing profits over safety and service, you will get more of the same.

TSB report defines the 'perfect world' that is the target to be attained.

The LE & MMA reside in the 'real world', and need to try harder to attain the TSB's world.

[Euclid]

dehusman

Euclid

But I don’t know why it should be necessary to push back against those arguments because the engineer OBVIOUSLY KNEW he had an engine problem.  He said the symptoms were abnormal.  The symptoms also included more than just excess smoke.  The excess smoke alternated from black to white, and the engine surged when under load.  The previous engineer on that locomotive observed and reported the same problem. 

Here's an excercise for you.  For the next month, as you drive to an from work, look at the cars and trucks around you.  How many of them have smoking tail pipes, how many have low air in the tires, how many have cracked windshields, how many have missing fenders or bumpers, how many are making lots of noises?  All of these people OBVIOUSLY KNOW they have a safety or mechanical defect in their car which could affect their personal safety and the safety of anybody who travels with them.  If you can see them, they can see them.  And yet day after day they will drive to their vehicles.  Not saying its right, just saying that once a person accepts a certain level of defects as "normal" those defects cease to be "defects" in their eyes.  It becomes SOP, just same sh*t, different day.  That's what causes accidents

Sure, drivers drive with safety and mechanical defects.  They take risks, break laws, and exercise bad judgment.  They ignore mechanical problems until they result in catastrophic failures.  But I am surprised that you would use this example of incompetence to defend the similar behavior of professional railroaders.   

[gardendance]

Biggest issue of all to me, after all these pages concerning which locomotive they should have left running to maintain brakes THEY WEREN'T SUPPOSED TO HAVE ANY LOCOMOTIVES for brakes. THEY WERE SUPPOSED TO HAVE SET ENOUGH HANDBRAKES to hold the train.

Even if the engineer thought the locomotive's problem was minor, didn't he shut down several other locomotives which he at least thought had no problems at all? Why did he decide to get up from the lead locomotive and shut down all the others? Was it more effort to have shut the lead down and skipped one of the following locomotives as he shut the rest down? Would it have been more effort the next morning to start up the lead locomotive, as opposed to one of the following locomotives?

Also, and all I know is what I read in these posts, didn't some of the other locomotives have some sort of auto start, which I assume means it would have tried to restart itself if it had a problem running while unattended?

[schlimm]

Euclid

Sure, drivers drive with safety and mechanical defects.  They take risks, break laws, and exercise bad judgment.  They ignore mechanical problems until they result in catastrophic failures.  But I am surprised that you would use this example of incompetence to defend the similar behavior of professional railroaders.   

At the risk of censure from Overmod, it sounds like Dave H.is defending willfully bad decisions.

[dehusman]

Euclid

But I don’t know why it should be necessary to push back against those arguments because the engineer OBVIOUSLY KNEW he had an engine problem.  He said the symptoms were abnormal.  The symptoms also included more than just excess smoke.  The excess smoke alternated from black to white, and the engine surged when under load.  The previous engineer on that locomotive observed and reported the same problem. 

Euclid

  But I am surprised that you would use this example of incompetence to defend the similar behavior of professional railroaders.   

 

I'm not defending their behavoir at all.  I've said all a long that there were lots of errors made.  My comments are pointed at your insistence that everybody involved OBVIOUSLY KNEW about the scope of the problem and how it would end up.  I'm just pointing out that assuming they OBVIOUSLY KNEW the scope of the problem isn't a good assumption because they could have been led astray by all sorts of factors which resulted in failure.  Part of the issue is that the management, as well as you, assumed the employees would  OBVIOUSLY KNOW there was a problem, what to do and how to do it.  My comments were pointed towards the underlying acceptance of exceptions as the norm which created an environment where a big failure could hide among all the little failures until the trap was sprung.  That's not excusing the failures, that's trying to figure out how that could happen.

[Randy Stahl]

Doesn't matter if the locomotive burned to the ground.. the train should have stayed put.

[Euclid]

dehusman

My comments are pointed at your insistence that everybody involved OBVIOUSLY KNEW about the scope of the problem and how it would end up.  I'm just pointing out that assuming they OBVIOUSLY KNEW the scope of the problem isn't a good assumption...

I never said that.  All I said is that they obviously knew there was a problem because of the symptoms.  You and others keep saying that the symptoms were not abnormal and so, nobody is responsible for ignoring them.  I never said they knew about the scope of the problem or how it would end up.  That would be a ridiculous assertion because it would be impossible to know the scope of the problem without tearing down the engine.   

[zugmann]

Randy Stahl

Doesn't matter if the locomotive burned to the ground.. the train should have stayed put.

+ 1000000000000000000000000000000005 I have no clue why Bucky is getting so wrapped up in locomotive mechanical 101. If the train was secured, PERIOD, there wouldn't have been an issue, junk power or not.

[wanswheel]

The train could roll down because not enough brakes were set. The train did roll down because a locomotive was dead.

Around midnight, Harding asks, “Do I need to go up there and start a…?” RJ interrupts, “No, no, no, no...”

I wonder if there was time for Harding to call a taxi, wait for it, ride to the train and start a locomotive.

[BaltACD]

wanswheel

The train could roll down because not enough brakes were set. The train did roll down because a locomotive was dead.

Around midnight, Harding asks, “Do I need to go up there and start a…?” RJ interrupts, “No, no, no, no...”

I wonder if there was time for Harding to call a taxi, wait for it, ride to the train and start a locomotive.

The train was not properly secured - PERIOD.  One handbrake on the train itself (not the locomotive consist) is not securing the train.

[Euclid]

zugmann

Randy Stahl

Doesn't matter if the locomotive burned to the ground.. the train should have stayed put.

+ 1000000000000000000000000000000005 I have no clue why Bucky is getting so wrapped up in locomotive mechanical 101. If the train was secured, PERIOD, there wouldn't have been an issue, junk power or not.

Well I am responding to those who keep saying that nobody should have had any idea that there was something wrong with the locomotive because no abnormal symptoms were presented.  This sounds like the same kind of lame excuse making that we had in the graffiti thread.

I agree that the failure to properly secure the train was the main cause of the disaster.  If the two supervisors never were told the details of the securement, and if there were no requirement for them to ask for the details; then I don’t see how they bear any responsibility. 

But in the larger perspective, the question is whether or not the engineer knew the proper securement procedure.  I don’t recall whether the report answers that question.  If it does answer it, I don’t know how the answer was determined.  But in any case, if the trial finds that the engineer did not know the proper securement procedure; and if he did not know that he did not know it; I think it will be hard to place much blame on him.

At that point, it seems to me that the blame shifts to higher levels of company management who are responsible for making sure their employees understand the rules.  I expect the deep insight revealed in the report will influence the addition of more criminal charges to others in the company. 

As to the relevance of the mechanical problem and engine fire, while it was not the main cause, it did indeed play a role.  The violation of the rule pertaining to a response to engine trouble; and the lack of rules testing and training on securement both played a role in forming a company culture that contributed to the cause of the accident. 

The report includes these findings which include the role of the malfunctioning locomotive as being pertinent:

3.0 Findings

3.1 Findings as to causes and contributing factors

1. MMA-002 was parked unattended on the main line, on a descending grade, with the securement of the train reliant on a locomotive that was not in proper operating condition.
2. The 7 hand brakes that were applied to secure the train were insufficient to hold the train without the additional braking force provided by the locomotive’s independent brakes.
3. No proper hand brake effectiveness test was conducted to confirm that there was sufficient retarding force to prevent movement, and no additional physical safety defences were in place to prevent the uncontrolled movement of the train.
4. 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.

[zugmann]

Well beck if we are going to list every contributing cause let's add the hill itself, gravity, and friction coefficients. Train wasn't properly secured. Smoke or no smoke.

[zugmann]

wanswheel

The train could roll down because not enough brakes were set. The train did roll down because a locomotive was dead.

I see it as the train could roll down because a locomotive was dead. The train did roll down because not enough brakes were set.

[wanswheel]

BaltACD

The train was not properly secured - PERIOD.  One handbrake on the train itself (not the locomotive consist) is not securing the train.

Yes, of course. But the failure of the locomotive is the sine qua non, the straw that breaks the camel's back.

[schlimm]

1.  The LE failed to secure the train properly, according to the rules.

2.  The LE did recognize the specific locomotive smoking was abnormal (as did the cab driver - no "'experts" needed to see that, apparently) and did express his concerns to the RTC, but was overruled or allowed himself to be overruled by the RTC, who had no training in understanding the mechanical condition of the locomotive's prime mover.

[BaltACD]

wanswheel

BaltACD

The train was not properly secured - PERIOD.  One handbrake on the train itself (not the locomotive consist) is not securing the train.

Yes, of course. But the failure of the locomotive is the sine qua non, the straw that breaks the camel's back.

Camel never entered the question and it's back is still strong.  The wrong tool (locomotive hand brakes)was used in the wrong manner (independent brake was applied during the securement test) and gave the LE the wrong answer about the securement of his train.

[Euclid]

I agree that the root cause was the failure to secure the train.  You can’t blame the engine for dying and releasing the air brakes because air brakes cannot be counted as securement.  This is the basic reason why it is invalid to blame the firemen (or anybody else) for shutting down the engine. 

Nevertheless, there is an interesting chain of rather unusual factors coming together.  Oddly the engine fire and fire department response was a small drama almost played as a miniature version of what was just around the corner as the train decided to head down to Lac Megantic.  People saw a train on fire and called the fire department.  Then that train went on to cause an astonishing fire.  

And the engine shutdown was an event in a pivotal role for the train to either allow the disaster or not. If the one locomotive did happen to stay running, everything would have been fine in the morning.  But if I remember, this was not the first time trains had been improperly secured.  Apparently, on those days, the faulty securement held because the compressor was pumping air.  But when the compressor was lost, the train was doomed. 

You can’t say the loss of the independent brakes caused the disaster.  But that loss of independent is one of the dominoes that fell that night. 

[schlimm]

Euclid

I agree that the root cause was the failure to secure the train.  You can’t blame the engine for dying and releasing the air brakes because air brakes cannot be counted as securement.  This is the basic reason why it is invalid to blame the firemen (or anybody else) for shutting down the engine. 

You can’t say the loss of the independent brakes caused the disaster.  But that loss of independent is one of the dominoes that fell that night. 

1. The failure to set sufficient handbrakes on freight cars to secure and to properly test, according to rules, was the responsibility of the LE ad the primary cause of the runaway.  And this was a part of a lax safety culture on the MMA.
2. However, the improper handling of the smoking lead engine was also an essential ingredient in the tragedy.  The engine fire could have been prevented if the LE had shut it down before leaving in the taxi.  But  he did not because haste in leaving that night (so not having to set more brakes and test) and haste to start moving in the morning (not having to start a cold engine) were valued, the latter by the RTC as well..

[Euclid]

I agree.  This report paints a broad picture.  Sometime shortly after this disaster, some Canadian official said that these kinds of disasters typically lie in a chain of events that uniquely came into alignment.  That certainly seems to be a theme of the report. 

But another theme that the report contains is that there is a higher level of responsibility for this disaster at Lac Megantic.  It would be a sort of systemic responsibility that goes to the management of the company.  It requires them to train their enginemen and conductors to comply with the rules rather than just tell them to read the rules and do what they say.       

[tree68]

schlimm

But  he did not because haste in leaving that night...

The general theme here has been that an insufficient number of brakes was set because 'that was how they did it.'  While I'm sure that the LE was anxious to leave, he didn't set enough brakes (as seen in hindsight) because he though he'd set enough brakes (using the independent, etc).

schlimm

(not having to start a cold engine)

I was of the understanding that the reason was to avoid having the train off air for more than four hours, which would necessitate a Class 1 (Number 1) brake test - hard to do with a single man crew.

[NP Eddie]

ALL:

I have read the many posts about the MMA accident.

The 18 in a row events that triggered that derailment reminded me of the 2007 I-35W bridge collapse in Minneapolis, MN.

First of all the bridge was under-designed with only 1/2" plate gusset plates. Secondly, the bridge was added to without reinforcing the bridge. Lastly, the bridge was under rehabilitation with dead weight of construction materials and vehicles on the surface of the bridge. Eventually the bridge collapsed with loss of life and many vehicles destroyed.

I tend to agree that not enough hand brakes were, but the locomotive engineer only operation was a contributing factor. One man cannot do the work of two. I have listened to the BNSF Staples Sub many times and when a train is parked for a new crew, the conductor will say something to the effect that both the engineer and I concur that enough hand brakes are set, although the Staples Sub east of St. Cloud, MN is fairly flat.

Ed Burns

Retired NP-BN-BNSF

[dehusman]

tree68

schlimm

(not having to start a cold engine)

I was of the understanding that the reason was to avoid having the train off air for more than four hours, which would necessitate a Class 1 (Number 1) brake test - hard to do with a single man crew.

 

Correct.  Most rule books or special instructions instruct the engineer to shut down all but the lead unit and leave the lead unit running to keep air on the train.  That's not being lazy it is almost universal policy on all railroads in N America.

[schlimm]

dehusman

That's not being lazy it is almost universal policy on all railroads in N America.

I did not say or imply the LE was being lazy.   I said he and the RTC (and the culture of the MMA, by implication from other posts and the report) valued haste.  And just because class ones leave locomotives running while sitting for hours unattended doesn't make it the right thing to do.

[wanswheel]

Excerpt from the Montreal Gazette, June 13, 2014

Lac-Mégantic: MMA employee statements to police unsealed

Harding left the train parked, unattended, and headed to Lac-Mégantic by taxi. On the way, Harding told driver André Turcotte that he had trouble with one of the locomotives earlier in the day. He also told Turcotte he really wanted to contact MMA’s American employees because they had more power and might tell him to turn the locomotive engine off, the warrant said.

http://www.montrealgazette.com/news/M%C3%A9gantic+employee+statements+police+unsealed/9936116/story.html#