I don’t know when the final report will come out, but we seem to have enough information at this point to understand what caused this disaster. The TSB has informed us that the train was composed of cars mostly having defective brakes. They were defective enough to make it impossible to control the train in normal running operation. However stopping with an emergency application of brakes was still possible despite the brake defects, so the train was stopped with an emergency application.
That was lucky because just prior to that emergency stop, the train was beginning a loss of braking process that may have resulted in the train running away on the descending grade. Fortunately the problem was realized and reacted to by making an emergency application which was able to stop the train. So, at that moment, disaster was averted. They were lucky.
Then at that point, they had a chance (and a duty) to diagnose the obvious problem and correct it. But they did not do that. Instead, they handed the train off to a new crew and made it their problem. In so doing, they set back into motion, the very disaster that they were so lucky to avert. The second crew was not so lucky. I wonder if somebody will be prosecuted for criminal negligence resulting in the deaths of three people.
Down the street from where my house is there is a plant for Vactor trucks. Their only truck receving dock is on my street for van trailers. Where my house is has a 6 ton weight limit after the plant so they have to blindside into the dock. There used to be a fire hydrant across the street from the plant notice how I said USED to be one. Well Swift used to also have the contract to deliver to Vactor here in town. After they took out the hydrant 5 times in 4 months including 3 times in the middle of winter plus twice ripping down the only power line next to it that feeds the township office across the street they lost the contract. We got it instead. As the plant VP put it when he called us up to offer it to us the costs of having us deliver it where cheaper than the repairs that they where dishing out to utility companies for damage Swift was doing to the infastructure around town. They moved the Hydrant to my side of the road and behind a set of steel bars. Why Yellow and Fed Ex drivers are not much better than Swift when it comes to backing up sometimes. They have hit the concrete wall that marks the edge of the factory property backing up. We send our local driver that his normal job is putting a 53 foot trailer into a hole designed for a 40 footer in a dock with 63 feet total distance to work with and he does it with one shot all day long. Our 1st street warehouse is that tight there is a creek in front of the property that we can not bridge.
Shadow the Cats owner I had to laugh my rear end off when I saw the CEO saying that a Simulator was the best way to train a new employee. Why I thought back to my own simulator training when I was in highschool in drivers education. Remember those people the ones were even if you smashed headlong into the wall nothing happened. Heck even the new ones are not much better. There are 3 OTR carriers that love simulators in their own training programs you can tell who they are by the number of crunched fairings on their trucks. Swift England and Werner all use simulators as part of their training programs to teach their new drivers how to back up. A simulator is great for teaching the basics but nothing beats how something feels in the seat of the pants going down the track or road.
I had to laugh my rear end off when I saw the CEO saying that a Simulator was the best way to train a new employee. Why I thought back to my own simulator training when I was in highschool in drivers education. Remember those people the ones were even if you smashed headlong into the wall nothing happened. Heck even the new ones are not much better. There are 3 OTR carriers that love simulators in their own training programs you can tell who they are by the number of crunched fairings on their trucks. Swift England and Werner all use simulators as part of their training programs to teach their new drivers how to back up. A simulator is great for teaching the basics but nothing beats how something feels in the seat of the pants going down the track or road.
Johnny
Those are dramatic all right but episodic. Historical (10 year) safety statistics are what are needed to draw any empirical conclusions about the "culture" [ugh, a horribly over/misused word, IMO].
BaltACD the train IS NOT developing sufficient braking power - PERIOD.
.
BaltACD charlie hebdo BaltACD CP has a SERIOUS safety culture problem and it starts at the Board Room. Can you show any empirical evidence? Euclid's videos! Such 'training' doesn't develop from the field up the chain - it comes from the top of the chain down as a means to cut costs - safety be damned.
charlie hebdo BaltACD CP has a SERIOUS safety culture problem and it starts at the Board Room. Can you show any empirical evidence?
BaltACD CP has a SERIOUS safety culture problem and it starts at the Board Room.
Can you show any empirical evidence?
Euclid's videos! Such 'training' doesn't develop from the field up the chain - it comes from the top of the chain down as a means to cut costs - safety be damned.
SIMULATOR PANACEA
Mr. Creel’s rather defensive posture and arrogant bragging about how simulators are a big timesaver says a lot about his style and what is going on at CP. It sounds like the sales pitch for simulators that he must have heard a thousand times.
Regarding his specific statement:
A unique operating hazard that may only occur every five years has nothing to do with the fact that the simulator is able to model and display that same hazard five times in ten hours. Those two facts have no logical connection. It is a clever sounding sales pitch for shallow minded people.
The real point is that a dangerous situation that can occur only every five years, might be overlooked in training; not that it takes a long time to train for. If it is overlooked in training, it will probably not be demonstrated by the simulator. Also, it is those rare dangers that are the most important to watch out for.
Rolling down the road is fine for providing a real world experience of how the rules come into play, but if the rules have not been vigorously taught in detailed methodology, rolling down the road can be just a joy ride.
Considering this runaway wreck:
The rules call for making an emergency application if the brakes are not holding the train at or below the maximum speed limit. The engineer did that. But what is supposed to happen next? It seems to me that there should be sufficient inspection to find out why the brakes were not holding the speed as they should have. How can a crew continue if they don’t know what the problem was? If you don’t know what the problem was, you do know that you have not fixed the problem. The only possible constructive outcome is that you may have given the problem enough time to fix itself.
It seems obvious to me that once the emergency application had safely stopped the train, the overwhelming management obsession was to get that train moving again. So not only did the crew not properly secure the train for recharging the trainline, but they also never looked hard enough to find the problem.
If they actually had found the problem of leaking brake cylinders, there was no way that train should have continued. The nature of the defect would have required sending out crews and locomotives to move the entire train to a place of safety where all the cars could be inspected and repaired to roadworthy standards.
I wonder how many times in ten hours, Mr. Creel’s simulators can show the engineer trainees and riding managers how a massive quantity of ill-maintained car brake cylinders can fail simultaneously when the temperature falls.
Never too old to have a happy childhood!
BaltACDCP has a SERIOUS safety culture problem and it starts at the Board Room.
BaltACD Euclid This seems to fit into the picture that is being painted: https://www.youtube.com/watch?v=apvcB9EINq0 So does this: https://www.youtube.com/watch?v=rjGyyB8dUo4 CP has a SERIOUS safety culture problem and it starts at the Board Room.
Euclid This seems to fit into the picture that is being painted: https://www.youtube.com/watch?v=apvcB9EINq0 So does this: https://www.youtube.com/watch?v=rjGyyB8dUo4
https://www.youtube.com/watch?v=apvcB9EINq0
So does this:
https://www.youtube.com/watch?v=rjGyyB8dUo4
CP has a SERIOUS safety culture problem and it starts at the Board Room.
I'm sure Creel couldn't get a locomotive off the shop track in one piece, forget about running a train.
Replicating a bad situation on a simulator would be a useful training exercise, but out in the real world it's the problems you didn't think of and don't expect that will get you.
Greetings from Alberta
-an Articulate Malcontent
EuclidThis seems to fit into the picture that is being painted: https://www.youtube.com/watch?v=apvcB9EINq0 So does this: https://www.youtube.com/watch?v=rjGyyB8dUo4
This seems to fit into the picture that is being painted:
SD70Dude BaltACD williamsb Yes but probably looking for another job. Better to be looking for a job than either feeding vegitation or be responsible for someone else feeding vegitation. After the initial 'firing', there are various appeal processes that take place in 'arenas' that are more fair than the Kangaroo Court that is conducted in field level company investigations. In situations such as this one, the employees would likely be reinstated with full back pay for time lost. In the appeals process, safety trumps shareholder value. I think it has been pretty well established right now that the relief crew (who of course died) were experienced, competent men, but we have not heard much yet about the previous crew who, and I quote from the TSB's preliminary report, "performed the required job briefing with a supervisor and the decision was made to set retainer valves to the high-pressure position on 75% of the cars on the train (84 cars)". On both CN and CP right now there are a lot of newer employees who, through no fault of their own have not received enough training and do not completely understand the inner workings of a car's air brake system. It looks to me like they asked for guidance, were given the wrong information, and did not know enough to realize that. Also, one brain is not operating at full capacity near the end of a long, stressful trip. RE: the appeals process, if one already has a long disciplinary record (deserved or not) they are not likely to fare well at arbitration. Perhaps someone here was already carrying 45 or 50 demerits, the weight of which would further influence a tired, stressed out brain.
BaltACD williamsb Yes but probably looking for another job. Better to be looking for a job than either feeding vegitation or be responsible for someone else feeding vegitation. After the initial 'firing', there are various appeal processes that take place in 'arenas' that are more fair than the Kangaroo Court that is conducted in field level company investigations. In situations such as this one, the employees would likely be reinstated with full back pay for time lost. In the appeals process, safety trumps shareholder value.
williamsb Yes but probably looking for another job.
Better to be looking for a job than either feeding vegitation or be responsible for someone else feeding vegitation.
After the initial 'firing', there are various appeal processes that take place in 'arenas' that are more fair than the Kangaroo Court that is conducted in field level company investigations. In situations such as this one, the employees would likely be reinstated with full back pay for time lost. In the appeals process, safety trumps shareholder value.
I think it has been pretty well established right now that the relief crew (who of course died) were experienced, competent men, but we have not heard much yet about the previous crew who, and I quote from the TSB's preliminary report, "performed the required job briefing with a supervisor and the decision was made to set retainer valves to the high-pressure position on 75% of the cars on the train (84 cars)".
On both CN and CP right now there are a lot of newer employees who, through no fault of their own have not received enough training and do not completely understand the inner workings of a car's air brake system. It looks to me like they asked for guidance, were given the wrong information, and did not know enough to realize that.
Also, one brain is not operating at full capacity near the end of a long, stressful trip.
RE: the appeals process, if one already has a long disciplinary record (deserved or not) they are not likely to fare well at arbitration. Perhaps someone here was already carrying 45 or 50 demerits, the weight of which would further influence a tired, stressed out brain.
I wonder what the experience of the Supervisor that made the decision to only use retainers is? Obviously, not much - he may know theory but doesn't know reality. A train that is having trouble with the braking system to start with will not be held by setting retainers - the train IS NOT developing sufficient braking power - PERIOD. Retainers will not increase the braking power of train that doesn't have enough braking power.
If the Supervisor is the one that actually made the decision of not applying hand brakes he now has the death of the relief crew members on his shoulders. Shoulders that should never make another decision on railroad operations on CP or any other railroad in the world.
Also, one's brain is not operating at full capacity near the end of a long, stressful trip.
Overmod ...there seem to have been an awful lot of downhill runaways with Canadians operating old and decrepit trainsets that seem not to have received adequate brake-system checking prior to being used on heavy grades...
...there seem to have been an awful lot of downhill runaways with Canadians operating old and decrepit trainsets that seem not to have received adequate brake-system checking prior to being used on heavy grades...
A quick recap.
December 11, 2011. Labrador Iron Mines ore train operated by Quebec, North Shore & Labrador:
http://www.tsb.gc.ca/eng/rapports-reports/rail/2011/r11q0056/r11q0056.pdf
January 10, 2018. CN coal train on the Alberta Coal Branch:
http://www.bst-tsb.gc.ca/eng/enquetes-investigations/rail/2018/r18e0007/r18e0007.html
February 4, 2019 (the subject of this thread). CP grain train on the Field Hill, crew killed:
http://www.bst-tsb.gc.ca/eng/enquetes-investigations/rail/2019/r19c0015/r19c0015.html
The TSB is currently performing a overhaul of their website, not all of their reports and preliminary findings are easily found right now.
BaltACD I believe the US air brake inspection period for cars is 5 years, the date is stenciled on each car. I would expect the appropriate seals to work in all weather conditions for that 5 year period. I don't know if the seals are required to be replaced during the 5 year COT&S inspection and service. I have no idea what the Canadian inspection and service period is.
I believe the US air brake inspection period for cars is 5 years, the date is stenciled on each car. I would expect the appropriate seals to work in all weather conditions for that 5 year period. I don't know if the seals are required to be replaced during the 5 year COT&S inspection and service. I have no idea what the Canadian inspection and service period is.
It doesn't matter what the inspection and overhaul requirements are if the railways ignore them, and Transport Canada does not properly monitor and enforce them.
That's been the sad reality out here for some time, where the car department (under pressure from management) performs No. 1 brake tests from a pickup truck at 15 mph and regularly misses cars with inoperative brakes, let alone those that set up and then leak off quickly.
BaltACDI am surprised they did not indicate when and where the last air brake inspection was performed the cars in their findings.
And who performed it. I don't know about CP, but around here, they got rid of a lot of car inspectors and have the conductors inspect their own trains. (Have to think of the shareholders!)
It's been fun. But it isn't much fun anymore. Signing off for now.
The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any
NDG,
Thanks for posting that report. Apparently that is an advisory about the unsafe covered hoppers.
But it does go into some detail about the accident background, and there is one sentence in the report that I do not understand. In this quote, it is the sentence which I have highlighted in red:
"About 10 minutes later, the train began to move on its own. The relief crew had not yet recovered the air brake pressure from the emergency brake application. The crew members were in the process of securing the train to facilitate the safe release and recharge of the air brakes."
It has been reported that the crew was waiting on the engine when the brakes released. But this sentence above says they were securing the train which I assume means outside setting handbrakes.
If they were outside setting handbrakes, did they run back to the engine and re-board the train?
NDG FYI. http://www.bst-tsb.gc.ca/eng/securite-safety/rail/2019/r19c0015/r19c0015-617-05-19-20190411.html#mb-pnl Thank You.
Thank You.
I am surprised they did not indicate when and where the last air brake inspection was performed the cars in their findings.
EuclidAlso playing a part in the terrible dilemma was the likely feeling that if they got off, there would be no possible way to prevent the catastrophic damage and financial loss that their employer expects its people to prevent.
Overmod,
I think it is quite likely that the seal weakness in this runaway train was due to the situation you refer to with cars being stored out of service for prolonged time. I can imagine those cars in grain service would see only seasonal use for the grain harvest, and would sit idle for the rest of the year or even longer.
I am not familiar with similar circumstances that led to runways that you refer to except for the runaway on QNS&L in 2011. The report on that one quite clearly details the issues of cylinder seals and testing, in addition to the issues of defective handbrakes. Both types of defects played a role in the runaway, and those cars had been in long term storage. Here is the report:
I too wonder about the apparent intention of holding the train with retainers alone. My impression from other comments here is that retainers alone could not possibly hold the train. Of course they could not hold it if most of the brake cylinders could not hold pressure due to leaking piston seals.
One thing about this wreck continues to puzzle me. That is the fact that the crew did not jump off the train when the brakes released on their own. Logically there was nothing they could do. I understand that the tunnel was just ahead, but they would know that there is sufficient clearance inside of the tunnel to allow a person to get off the train.
I suspect they fell into a state of disbelief and adopted a kind of group think in which each one hoped that one of the others had solution to the problem. So, then together as a group, they just could not decide to get off. Also playing a part in the terrible dilemma was the likely feeling that if they got off, there would be no possible way to prevent the catastrophic damage and financial loss that their employer expects its people to prevent. Even though it would not have been the crew's fault, they must have felt some responsibility to stay with the train in case they found that something could be done about the problem.
There are certain trackside situations where jumping of would likely be fatal, such as a high trestle with no walkway or deep, hard snow banks shaped by the locomotives, and offering no clearance for a person between the snowbank and the engine and car trucks. I don't know if that type of snow formation existed at the point where the train was standing.
EuclidHere is the way railroad companies probably look at the issue: ... There is nothing critical about a bad piston seal because most of the consist will have good working seals and one bad seal in a train will not matter ... However, if one car with a bad seal is not important, there is no need to go looking for that problem. And if it is okay to dismiss the importance of one bad seal, pretty soon there will be more bad seals. Eventually, there will be a great number of cars with seals that will only be performing properly at relatively warm temperatures ... Whole trains will consist of cars with such degraded seals. Then one day a whole train of cars with bad order seals will be operating in temperatures too cold for sufficient sealing ability.
That does not appear to be the mechanism in any of these Canadian downhill runaways. What seems to be happening is that the cars were sitting idle in blocks for some number of years, while the cups aged and perhaps stuck to the bores and the foundation gear rusted, and were then put back into service en masse without full maintenance being performed 'as it should be'.
That gives you in essence a whole train with bad seals, excessive slack, inability to wind up handbrakes properly, etc. all at the same time.
I am still trying to conceive of a world in which the reported train could have been held on that grade with 'retainers' alone, let alone in cold weather, let alone through a release and recharge without a huge proportion of handbrakes not just cranked on but fully applied.
5 years before any inspection of a brake cylinder seal. That's a lot of miles and time on something that sees a heck of a lot weather and operations.
Yes more frequent inspection would cost more however it may also catch a few problems before derailments like this one happen again. My boss has over 500 trailers and all of them see the shop for an inspection at least once a year for a required annual inspection of trailer and quarterly for maintenance. Even though our drivers still find issues between visits to the shop. But 5 years before a major look at the brake system. Yes I know that they look at them in a class 1 brake test for movement and such. However that's not checking for worn out seals and leaking from the parts.
Yes, I would normally associate the term packing as what seals a piston rod, but Wabtec calls them “Brake cylinder packing cups.” So I chose their nomenclature.
https://www.wabtec.com/products/1269/brake-cylinder-packing-cups
I agree that usage would determine life as would aging time. So a time limit alone would not insure that the seals were working. My basic thought is that I would not expect it to be considered acceptable for the seals to work fine in warm weather, but become questionable as the temperature falls. That would be flawed performance. So there should be a way to know that the seals are able to perform within a specified temperature range that includes all temperatures that might be encountered. Otherwise, people will just dismiss a seal failure as something that must be expected in cold weather. I hear this dismissal often.
Here is the way railroad companies probably look at the issue: Loose cars move in random mixes of consist. A bad piston seal will eventually be found and replaced. There is nothing critical about a bad piston seal because most of the consist will have good working seals and one bad seal in a train will not matter. It does not affect anything but the brakes of the car with the bad seal. This would be a way to rationalize that the need for seal inspection and maintenance is never critically important because any bad seal will be protected by all the rest of the consist with okay seals.
However, if one car with a bad seal is not important, there is no need to go looking for that problem. And if it is okay to dismiss the importance of one bad seal, pretty soon there will be more bad seals. Eventually, there will be a great number of cars with seals that will only be performing properly at relatively warm temperatures. Whole trains will consist of cars with such degraded seals.
Then one day a whole train of cars with bad order seals will be operating in temperatures too cold for sufficient sealing ability. The problem will first show up in that train not being able to hold its speed down on a descending train. This will prompt an emergency application to stop and find the problem. Then shortly, the emergency application will leak off of nearly every car in the train due to the bad brake cylinder seals.
Part of the confusion here is that 'packing seals' normally apply to seals around a rod or shaft, as in the 'metallic packing' used on steam locomotives. The piston seals are the elastomer 'cups' that seal the piston as it slides in the cylinder bore; since the air only 'applies' one way, cups can be used instead of piston rings or O-rings, either of which would require more adjustment or lubrication, and likely suffer more early blow-by, than a good cup would.
It was my understanding that different compositions of elastomer in the piston seals were used for cold-weather operation -- there may even be a range of different compositions for anticipated service temperatures vs. longest operational life.
There is no question that the piston cups will wear in service, and I have little doubt that they harden or degrade over time. If I remember correctly there is a limited amount of permitted leakage when a car is tested for service, and the sum of that leakage mass flow over a train's worth of cars 'at that limit' might be considerable in absolute terms. I do not recall that there is any formal "age" limit (as any age-related leakage would only contribute to detected leakage rate on test) although it is possible that catastrophic degradation of 'seal integrity' might occur as what would appear to be a common-mode failure, in part due to age-related deterioration. I expect the Canadians to discuss this if it turns out to be a factor here, but there seem to have been an awful lot of downhill runaways with Canadians operating old and decrepit trainsets that seem not to have received adequate brake-system checking prior to being used on heavy grades...
BRAKE CYLINDER PISTON PACKING SEALS
According to the news, the first crew did not set any handbrakes, but they did set retainers on the train; presumably as a means to hold the train.
It is widely understood that cold weather can make the charging of the trainline slower than normal because of leakage. The leakage is always said to be occurring at the glad hand gaskets at each air hose coupling. In the case of this wreck, the leakage was apparently occurring from brake application air stored in each brake cylinder and its connected air reservoir.
In each brake cylinder, this air would be leaking past the brake cylinder piston from the pressure side of the piston to the non-pressure side. What normally prevents such leakage is a rubber packing cup around each brake cylinder piston.
The important difference between glad hand gasket leakage and brake cylinder piston leakage is that the former can only cause moving trains to stall or standing trains to be unable to raise or maintain pressure in the trainline; while latter can cause brakes to fail to slow the train or to stop as expected.
With either of these two types of leakage, the immediate cause is cold weather causing the rubber seals to lose their elasticity. In normal use, the seals are compressed and their desire to return to their uncompressed state is always present. That constant return force maintains an airtight connection between the sealed components. But if it is too cold, the rubber loses its desire to return to its uncompressed state if it is compressed. And without that characteristic, the seal fails to hold pressure.
Here is what I wonder: If these piston or glad hand seals are new, do they work as they should in all temperatures encountered in railroad service? And then only when they reach a certain age, do they suddenly become incapable of performing properly? In other words, do the seals have a specified operating life during which they meet all performance requirements?
I would think that the piston packing cup seals cannot be allowed in service if they will not perform perfectly in the coldest weather possible. I don’t see how one can excuse seal failure just because it was very cold weather. The proper functioning of the piston seals is just as important as an air test.
People say you cannot rely on air to hold a train stopped. But you have to rely on air to hold the train for at least as long as it takes to set handbrakes. That can take an hour or more to accomplish.
Therefore, a piston seal must have a prescribed guaranteed operating life, after which the seal must be replaced or the car must be taken out of service. If this were the case, a runaway such as this one on the CP could not have been caused by leaking brake cylinder piston packing seals. And if it were caused by that condition, it would follow that the seals had not been replaced when they reached the end of their guaranteed operating life.
williamsb If CP says not to apply handbrakes after an emergency application and the crews spent 4 or 5 hrs putting on and taking off handbrakes how much trouble do you think they be in with management?
If CP says not to apply handbrakes after an emergency application and the crews spent 4 or 5 hrs putting on and taking off handbrakes how much trouble do you think they be in with management?
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