Good video, interesting issues raised by CBC.....
https://www.youtube.com/watch?v=RstfTeV3X_4
CMStPnPGood video, interesting issues raised by CBC..... https://www.youtube.com/watch?v=RstfTeV3X_4
Whomever instructed the original crew not to secure the train with hand brakes is the culpable party.
The Relieving crew walked into a Death Trap and sprung it.
Never too old to have a happy childhood!
Regarding the comment made in the family meeting about grain hoppers being pulled from service for inspection and repairs; for the past two to three years the Federal government in Canada held CP and CN both accountable for not moving what the government felt was sufficient quantities of grain. The railway's reaction to this was to start priortizing grain movement to the point that it was negatively impacting the movement of other products in western Canada.
If - and I stress "if" CP was not properly inspecting and repairing grain equipment it likely was directly related to the government's insistence they must move certain quotas of grain or face substantial penalties. Kind of a "damned if you do and damned if you don't" situation.
Curt
CMStPnP Good video, interesting issues raised by CBC..... https://www.youtube.com/watch?v=RstfTeV3X_4
Interviews w the Crew that got OFF the train might be revealing?
Thank You.
Juniata Man Regarding the comment made in the family meeting about grain hoppers being pulled from service for inspection and repairs; for the past two to three years the Federal government in Canada held CP and CN both accountable for not moving what the government felt was sufficient quantities of grain. The railway's reaction to this was to start priortizing grain movement to the point that it was negatively impacting the movement of other products in western Canada. If - and I stress "if" CP was not properly inspecting and repairing grain equipment it likely was directly related to the government's insistence they must move certain quotas of grain or face substantial penalties. Kind of a "damned if you do and damned if you don't" situation.
The corporate practices of both railways over the last 20 years resulted in reduced investment in the physical plant, and even some capacity reduction projects. I'm saying that as nicely and quickly as possible.
The regulations on car inspections, maintenance intervals, and train braking capabilities are very clear, and have changed little over the past few decades. If the railways cannot find the time to maintain the existing car fleet and also meet customer and government expectations, then they obviously do not have enough cars. The solution is to buy or lease more cars, not cease to perform proper maintenance.
And they have been cutting back on car maintenance. For some years car inspectors have been performing No. 1 air brake tests by driving beside the train, which does not allow for a proper visual inspection of many parts of a railcar. Transport Canada is at fault for allowing the railways to implement this sort of practice.
It is important to note here that train crews are not allowed to perform No. 1A air tests (check brake application and release) from a vehicle, we must walk.
It is also important to note that the cylindrical 'Trudeau' hoppers that still compose a large part of the Canadian grain car fleet have truck-mounted air brakes. This design has much smaller pistons, which are very difficult to see. I would say they are nearly impossible to check properly if one is sitting in a vehicle.
Among other things, the Canadian regulations state that a train must have 85% operative brakes, and must not leave a safety inspection location (where car inspectors are employed) with less than 95% operative brakes. Any inoperative brakes must be noted on the crew's paperwork. There have been numerous occasions where trains have left with inoperative brakes that are not noted on the Train Brake Status Report (TBSR) provided to the crew, and when the company has been questioned about this the usual response is "vandals must have done it".
While it was not publicized, CN had a runaway coal train in January 2018 on a steeply graded branchline. After this crews operating on that line were required to perform an additional brake test before descending the grades. And they started finding many, many cars with inoperative brakes. When these cars were reported to the mechanical department little was done, and many continued in operation for weeks or months, despite being reported over and over again. Again Transport Canada was made aware of this, and aside from some stern words nothing real was done.
This is the incident I am referring to. I used to work on that line, and still have friends who do. The grade there is about 3%.
https://www.tsb.gc.ca/eng/enquetes-investigations/rail/2018/r18e0007/r18e0007.html
Greetings from Alberta
-an Articulate Malcontent
SD70; if CN and CP are lax about inspecting and bad ordering their own equipment; it's probably because they determined they could juice their bottom lines by bad ordering and repairing private equipment.
After the widespread deployment of WILD detectors; private car wheel replacement costs went through the roof. Yet, when I've had a spare moment to stand and watch a train go by; it seems most flat spots are now on equipment with railroad reporting marks.
I questioned several different railroad folks at times asking if they had any data to indicate the incidence of flat wheels on private cars versus that of railroad equipment. The response invariably was a terse "no" - next question?
Yeah, that sounds about right. Find even more creative ways to bill the customers.
But it still does not excuse them from failing to take the time to properly maintain their own fleets.
NDG CMStPnP Good video, interesting issues raised by CBC..... https://www.youtube.com/watch?v=RstfTeV3X_4 Interviews w the Crew that got OFF the train might be revealing? Thank You.
It sure seems like such interviews would be revealing. As I recall, the previous crew was having problems with braking, and so they made an emergency application. This was the application that was left holding the train for the crew change. Somehow, I had also understood that there was no requirement to secure the train with handbrakes; except subject to some conditions. I don't quite recall those conditions, but they may have related to the amount of time the train was left with only the emergency application holding it.
In any case, in the video above, they seem to say that setting hand brakes was not required unless there was evidence of a braking problem prior to stopping. It sure seems like that was the case with this train. So that would be the fine point that the company would hang their hat on. I guess it would depend on the meaning of "knowing the train had a braking problem" prior to stopping. So, yes, interviewing that crew that dumped air to stop the train would be interesting.
But the most incredible warning, as I see it, would have been when the new crew had boarded the engine for departure, and the emergency application simply released on its own. It would seem that they would have realized that the train would be immediatly out of control. I assume there was plenty of communication between various parties when the train started to roll away unexpectedly.
I think we know that the brake air application released due to leaking cylinder packing. What we don’t know is why the handbrakes had never been set as insurance against an unintended release. I will speculate that the reason for not setting handbrakes was the time and effort it would have taken. The train was deemed to be under control as long as the air application held. That was believed to be good enough.
Actually, it is the same reason that insufficient handbrakes were set at Lac Megantic. However, at Lac Megantic, the rules were clear and the need for setting the handbrakes was clear during most of the aftermath discussion.
According to the video above, there was no requirement to set handbrakes on the train that ran away at Field, BC unless certain conditions existed. At least one of those conditions is said to have been the existence of braking problems prior to stopping.
If that is the case, then the only justification for not setting handbrakes after the train stopped was that the existence of braking problems had not been discovered. There was speculation that braking problems had existed prior to stopping, but that was only speculation and not proven. So that leaves this question:
Does circumstantial evidence of a braking problem constitute a braking problem?
If I recall correctly, the engineer who brought the train into Field, BC reported experiencing braking problems with the train. This amounted to the train not decelerating as fast as would be expected. That was said to be the reason he stopped the train at Field with an emergency application. However, an operating failure of the brakes had not actually been diagnosed with sufficient testing and inspection to fully understand and confirm a braking defect. So apparently, the person in charge decided that there was no braking problem, and thus no need to set handbrakes.
But for me, the larger question is why the second crew did not get off the train when the emergency brake application suddenly released without any control input from the engineer. At that point, what hope could there possibly be that train would not run away, speed up, and pile up on a curve? If that outcome is inevitable, why stay on and try to ride it out?
Wonder why charges of involuntary manslaughter have not been laid at the responsible operating officials . . .
- PDN.
Why even bother asking the CEO about it, that is so below his level of office in the company that I'm even surprised he answered the questions. Isn't danger part and parcel of the job? isn't that what repeater cars are for, or is CN the only one to use them? Was it tragic, yes and it was an accident, but was the cause of the accident negligence or just failure to follow operating rules. Also, why call in a death investigator and corporate criminal lawyer...what do they know about railroading? Also, those families expecting answers after only 10 months, don't they know TSB/NTSB investigations take a couple of years at least? Way to many questions to answer we have to answers for.
A company official telling the original crew NOT TO APPLY HAND BRAKES, when the train was stopped because of braking issues in the first place was the cause. What if any effective communication was passed between the original crew and the relieving crew was a contributing cause.
Gerald, your comments show basic ignorance of the work environment railroaders operate in.
GERALD L MCFARLANE JR Isn't danger part and parcel of the job?
Isn't danger part and parcel of the job?
It is easy to type stuff like that on a keyboard, but do you plan to tell me to my face that I have no right to properly operating brakes on my train? And do you think it is ok for management to take the quicker course over the safe one, as was done when instructing the original crew to set retainers and not handbrakes?
Things like handbrakes, air brakes, and the operating rules exist to mitigate the risks in railroading. They must be properly used, maintained and obeyed, which does not appear to have happened on that fateful winter night.
GERALD L MCFARLANE JR isn't that what repeater cars are for, or is CN the only one to use them?
isn't that what repeater cars are for, or is CN the only one to use them?
I don't believe CP uses aircars, but that is irrelevant because they would not have helped in this situation. The aircar's purpose is to help set and release the brakes on a long train more quickly, they do nothing to help hold the train still. Train 301 was already set up in a 1x1x1 Distributed Power configuration, with a remote locomotive in the middle and an another on the tail end of the train. It doesn't get any better than that for pumping air.
GERALD L MCFARLANE JR Was it tragic, yes and it was an accident, but was the cause of the accident negligence or just failure to follow operating rules. Also, why call in a death investigator and corporate criminal lawyer...what do they know about railroading? Also, those families expecting answers after only 10 months, don't they know TSB/NTSB investigations take a couple of years at least? Way to many questions to answer we have to answers for.
Was it tragic, yes and it was an accident, but was the cause of the accident negligence or just failure to follow operating rules. Also, why call in a death investigator and corporate criminal lawyer...what do they know about railroading? Also, those families expecting answers after only 10 months, don't they know TSB/NTSB investigations take a couple of years at least? Way to many questions to answer we have to answers for.
Failure to obey operating rules and use the available technology properly and safely constitutes negligence. Writing rules that do not require the safe course to be taken would also constitute negligence on the part of the company.
The investigators and lawyers have likely dealt with other cases of corporate negligence before, and will be able to make comparisons and judge whether or not this case 'makes the cut'.
While the TSB does not release their reports for years, they will usually have a pretty good idea of what happened within month or two after the incident. Here is their preliminary findings, which explain quite clearly what happened that night:
https://www.tsb.gc.ca/eng/securite-safety/rail/2019/r19c0015/r19c0015-617-04-19-20190411.html
https://www.tsb.gc.ca/eng/securite-safety/rail/2019/r19c0015/r19c0015-617-05-19-20190411.html
BaltACD A company official telling the original crew NOT TO APPLY HAND BRAKES, when the train was stopped because of braking issues in the first place was the cause. What if any effective communication was passed between the original crew and the relieving crew was a contributing cause.
Well said.
SD70Dude BaltACD A company official telling the original crew NOT TO APPLY HAND BRAKES, when the train was stopped because of braking issues in the first place was the cause. What if any effective communication was passed between the original crew and the relieving crew was a contributing cause. Well said.
What I don't comprehend is why the crew rode the train to the derailment rather than dismounting once they observed the train starting to move when it was in a condition 'that in their minds' it still should have been stationary. It does take time for the train to accelerate from Zero MPH, so, to my mind there was time to try a 'trick or two' and observe they weren't working and dismount at a 'near safe' speed.
I am seeking clarification:
The following is a quote from the first attached report from TSB (posted above by SD70Dude) in which, after this runaway, they add a requirement to secure trains with handbrakes:
“Following the occurrence [the runaway train], on 8 February 2019, Transport Canada (TC) issued Ministerial Order MO 19-03 (Annex A) requiring that trains stopped by an emergency brake application on a grade of 1.8% or greater (i.e., mountain grade) immediately apply a sufficient number of hand brakes before recharging the air brake system.”
Notice that the last sentence has two conditions pertaining to the application of handbrakes, as follows:
Handbrakes must be applied before recharging the air brake system.
Handbrakes must be applied immediately after stopping.
This Ministerial Order (shown above in red) raises the following questions:
Prior to the order, was there no requirement to apply handbrakes; or was there a requirement to apply handbrakes under a different set of conditions which are replaced by the two conditions given in the order above?
If prior to the order, there was a different set of conditions for applying handbrakes when a train stops on a grade of 1.8% or greater, what were those conditions?
In other words, what exactly did the order (shown above in red) change? Of the two conditions of the order (that I have listed above), the second crew was complying with the condition requiring that handbrakes be applied before recharging the airbrake system.
ALSO: Prior to the order (shown above in red), when the train stopped on the grade in this case, was there or was there not a requirement to immediately apply handbrakes?
EuclidNotice that the last sentence has two conditions pertaining to the application of handbrakes, as follows: Handbrakes must be applied before recharging the air brake system. Handbrakes must be applied immediately after stopping.
We've had extensive discussions about this before. Including considerable technical discussion about telemetric application of multiple emergency brakes in parallel, under power, and telemetric, possibly staged, release of emergency brakes when no longer required.
You can always tell a Government order by its mandatory insistence on impossible operations. It costs little for a twentysomething staff to write up a mandate about 'immediate' application of brakes; it's quite a different thing when a crew with other mandated duties is expected to walk back along a consist tightening brakes that might have been maintained last by agrarian workers in 2006 so they absotively, posilutely apply with full force and effect. (Note the conscious use of a term familiar to twentysomething bureaucratic staff, in a context they might not recognize as unrelatable).
You may recall that when you look at the actual number of handbrakes the TC actually calculated itself would be required to bring this about on the train at Field, it worked out to being something like 78, or an appreciable percentage of the train length. I really see a reduced crew getting this done right after an emergency event ... perhaps a repeated one with a dynamiter in the consist ... before they can attend to anything else involved with train handling. It will take some time to apply all those brakes, all completely done before any release and recharge can begin, or really before more than a cursory inspection of the train for the 'cause' of the emergency application can be consciously undertaken ... then more time still to set the train brake sufficiently to hold it and then go back to release all those brakes (and check each to make sure it has fully released at the wheels) to permit the train to actually start downhill under "legal" control. (All this begging the associated question of 'how do you know you have enough application before all the brakes are released' or if the train starts to move while folks are still ratcheting or brakesticking away back there.)
I know for a fact I've seen answers to the 'different condition' question in previous threads, both on this subject and in other TCA brake-related accident reports that have gone by. As I recall, they related to the 'minimum number of effective brakes' that regulations required to be applied, which of course was a pathetic number pathetically construed at the time of the Lac Megantic runaway.
The elephant in the room, then and now, is the quiet understanding of just how many brakes, potentially imperfect brakes at that, actually need to be applied to hold a train safely by modern standards of safety. That number is not a happy one for shoestring single-man operations, but it is also not a happy one for PSR-crazed people wanting to economize on all that non-profitable human-capital stuff. The ongoing problem is that 'it is what it is.'
BaltACD What I don't comprehend is why the crew rode the train to the derailment rather than dismounting once they observed the train starting to move when it was in a condition 'that in their minds' it still should have been stationary. It does take time for the train to accelerate from Zero MPH, so, to my mind there was time to try a 'trick or two' and observe they weren't working and dismount at a 'near safe' speed.
cx500 BaltACD What I don't comprehend is why the crew rode the train to the derailment rather than dismounting once they observed the train starting to move when it was in a condition 'that in their minds' it still should have been stationary. It does take time for the train to accelerate from Zero MPH, so, to my mind there was time to try a 'trick or two' and observe they weren't working and dismount at a 'near safe' speed. The situation here was that almost immediately past the end of the siding the track enters the Upper Spiral Tunnel. There would have been very little time available to try a "trick or two", which quite possibly was the initial reaction, before the tunnel made bailing off impossible. Re-emerging into daylight after something like 3/4 mile (IIRC) of 2.2% grade the speed attained continued to make it a questionable option. There was the possibility that the lead unit might have made it down to the bottom, as that happened with a different runaway event 25 years earlier. I don't think the reports have detailed exactly how much time elapsed between the crew climbing aboard and the train starting to move. John
I don’t understand how it was physically possible for the train to have rolled away with no braking capability and with the crew onboard the engine.
According to TSB, the crew was not on the engine when the emergency application suddenly released and train began to roll away. They were out climbing around on the train setting handbrakes in preparation to recharge the trainline, and it was during that activity that the train began to roll.
It is possible that they had finished setting the handbrakes and re-boarded the engine when the emergency application suddenly and unexpectedly released. But if that is what happened, the train would not have rolled away when the emergency application released because they had just tied it down with handbrakes.
From the TSB report:
“After an extended period of about 2 hours 45 minutes, a relief crew arrived to replace the crew at Partridge, whose maximum hours of service had been reached. 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.”
EuclidI don’t understand how it was physically possible for the train to have rolled away with no braking capability and with the crew onboard the engine.
Reading between the lines: the crew was assuming that the emergency set would hold indefinitely; something that remains to be actually seen is whether they might have been 'instructed' not to go over hours of service in more than minimal numbers to keep cranking train brakes on. It would appear that the engineer from the relief crew had not boarded at the time the train began to move; perhaps he was 'helping out' with brake setting before assuming responsibility on the engine.
The emergency set released before anywhere near an adequate number of securing handbrakes had actually been set, by however many people were back on the train setting them. (The train would either not have moved, or accelerated more slowly, otherwise...)
It was evidently impossible to conduct a full release and recharge of the 'leaked-down' brake system (whether or not there was someone on the engine who promptly undertook that) before the train had accelerated to the speed at which even full brake application wouldn't have held the train, probably at least roughly comparable to the 23 or so mph for the relevant parts of 17 Mile Grade. I suspect that speed would be independent of considerations related to the number of actually applied handbrakes as those would be fading at least as quickly as any others applied with more pressure behind them...
Euclid From the TSB report: “After an extended period of about 2 hours 45 minutes, a relief crew arrived to replace the crew at Partridge, whose maximum hours of service had been reached. 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.”
The fact that all three crew members were found on or in the immediate vicinity of the lead locomotive by default states they were not on the ground setting hand brakes. Did the TSB 'manufacture' a scenario of what the crew was doing?
Overmod It would appear that the engineer from the relief crew had not boarded at the time the train began to move; perhaps he was 'helping out' with brake setting before assuming responsibility on the engine.
I don't follow you. If the engineer had not boarded prior to the time the train began to move, when did he board? Wasn't the engineer one of the three people killed in the runaway?
I recall learning that there was not a requirment to set handbrakes immediatly upon stopping on such a grade as the one in this accident. Instead, there was a grace period of 2 hours, which apparently was a reflection of a belief that an emergency application could be trusted for that amount of time, thus saving the labor of handbrake securement.
I am not fully convinced that this is true, but it does fit the statement in the video above. It also fits with the TSB issuing a special new order requiring handbrakes to be set immediately upon stopping. This implies, that prior to the special order, handbrake setting was NOT immediately required upon stopping.
Overmod Euclid Notice that the last sentence has two conditions pertaining to the application of handbrakes, as follows: Handbrakes must be applied before recharging the air brake system. Handbrakes must be applied immediately after stopping. We've had extensive discussions about this before. Including considerable technical discussion about telemetric application of multiple emergency brakes in parallel, under power, and telemetric, possibly staged, release of emergency brakes when no longer required. You can always tell a Government order by its mandatory insistence on impossible operations. It costs little for a twentysomething staff to write up a mandate about 'immediate' application of brakes; it's quite a different thing when a crew with other mandated duties is expected to walk back along a consist tightening brakes that might have been maintained last by agrarian workers in 2006 so they absotively, posilutely apply with full force and effect. (Note the conscious use of a term familiar to twentysomething bureaucratic staff, in a context they might not recognize as unrelatable). You may recall that when you look at the actual number of handbrakes the TC actually calculated itself would be required to bring this about on the train at Field, it worked out to being something like 78, or an appreciable percentage of the train length. I really see a reduced crew getting this done right after an emergency event ... perhaps a repeated one with a dynamiter in the consist ... before they can attend to anything else involved with train handling. It will take some time to apply all those brakes, all completely done before any release and recharge can begin, or really before more than a cursory inspection of the train for the 'cause' of the emergency application can be consciously undertaken ... then more time still to set the train brake sufficiently to hold it and then go back to release all those brakes (and check each to make sure it has fully released at the wheels) to permit the train to actually start downhill under "legal" control. (All this begging the associated question of 'how do you know you have enough application before all the brakes are released' or if the train starts to move while folks are still ratcheting or brakesticking away back there.) I know for a fact I've seen answers to the 'different condition' question in previous threads, both on this subject and in other TCA brake-related accident reports that have gone by. As I recall, they related to the 'minimum number of effective brakes' that regulations required to be applied, which of course was a pathetic number pathetically construed at the time of the Lac Megantic runaway. The elephant in the room, then and now, is the quiet understanding of just how many brakes, potentially imperfect brakes at that, actually need to be applied to hold a train safely by modern standards of safety. That number is not a happy one for shoestring single-man operations, but it is also not a happy one for PSR-crazed people wanting to economize on all that non-profitable human-capital stuff. The ongoing problem is that 'it is what it is.'
Euclid Notice that the last sentence has two conditions pertaining to the application of handbrakes, as follows: Handbrakes must be applied before recharging the air brake system. Handbrakes must be applied immediately after stopping.
As one who uses the handbrake chart and rules on a daily basis at work, I think the current version makes sense.
"Handbrakes must be applied before attempting to recharge" is there for obvious reasons.
"Handbrakes must be applied immediately after stopping" is not interpreted to mean that all 80 handbrakes must be tightened instantaneously within X-number of seconds after stopping in emergency. It means that the crew must begin the process of applying handbrakes as soon as the train comes to a stop.
Before this, the normal first step for an inexperienced crew who finds themselves in this unenviable situation would be to call the Dispatcher and ask for instructions from the Road Foreman of Engines (or whatever your railroad calls them, it's Engine Service Officer on CN). This communication and decision process can take a surprising amount of time, meanwhile the emergency air brake application is leaking off.
Applying dozens of handbrakes takes a significant amount of physical effort and time, and many crews and managers alike will look for alternatives before resorting to this torturous task. I myself once fell into that category when I was new and did not understand air brakes as well as I do now. I am not proud of my past ignorance, and I was lucky enough to not work in heavy grade territory when I was new.
Later on I ended up working some jobs where I had to apply over 30 handbrakes at once on a regular basis, by myself. It is NOT fun, but it was and is necessary in these situations.
I find the handbrake chart to err on the side of caution, which is good, though it does not differentiate between cars with body and truck-mounted air brakes. The handbrake on many cars with truck-mounted air brakes will only apply on the B-end truck, therefore such a handbrake will only provide half the braking effort, while requiring approximately the same amount of physical exertion to apply (ask me how I know).
This makes sense, and you know the territory far better than I ever will.
I heard, from a reputable source within my Union, that the Conductor and Trainee were out applying handbrakes and the Engineer was in the lead locomotive cab when the train started to roll. The Conductor and Trainee then sprinted ahead and reboarded the lead locomotive as the train continued to accelerate.
Why would they do something like this, instead of jumping off while they still had a chance? With hindsight being 20/20 it seems the obvious choice, but in the panicked heat of the moment they still tried to save the train.
Whatever "trick or two" they might have tried (and I can think of a couple possibilities) sadly did not work.
[quote user="SD70Dude"]
SD70Dude As one who uses the handbrake chart and rules on a daily basis at work, I think the current version makes sense. "Handbrakes must be applied before attempting to recharge" is there for obvious reasons. "Handbrakes must be applied immediately after stopping" is not interpreted to mean that all 80 handbrakes must be tightened instantaneously within X-number of seconds after stopping in emergency. It means that the crew must begin the process of applying handbrakes as soon as the train comes to a stop. Before this, the normal first step for an inexperienced crew who finds themselves in this unenviable situation would be to call the Dispatcher and ask for instructions from the Road Foreman of Engines (or whatever your railroad calls them, it's Engine Service Officer on CN). This communication and decision process can take a surprising amount of time, meanwhile the emergency air brake application is leaking off. Applying dozens of handbrakes takes a significant amount of physical effort and time, and many crews and managers alike will look for alternatives before resorting to this torturous task. I myself once fell into that category when I was new and did not understand air brakes as well as I do now. I am not proud of my past ignorance, and I was lucky enough to not work in heavy grade territory when I was new. Later on I ended up working some jobs where I had to apply over 30 handbrakes at once on a regular basis, by myself. It is NOT fun, but it was and is necessary in these situations. I find the handbrake chart to err on the side of caution, which is good, though it does not differentiate between cars with body and truck-mounted air brakes. The handbrake on many cars with truck-mounted air brakes will only apply on the B-end truck, therefore such a handbrake will only provide half the braking effort, while requiring approximately the same amount of physical exertion to apply (ask me how I know).
In my quote in blue, I was referencing the order issued by TC after the wreck. When they say handbrakes must be applied immediately after stopping, like you, I interpret that to mean starting the application process immediately after stopping as opposed to waiting for some time before starting. I understand your point that the application takes a lot time.
However, this is the rule after the wreck as imposed by the new order. This rule suggests that something was changed from previous rules. It seems that before the change, the rules allowed up to 2 hours after stopping before starting to apply handbrakes. This is indicated by TC's description of what actually happened during the operations on the day of the wreck.
Euclid Euclid said: "Notice that the last sentence has two conditions pertaining to the application of handbrakes, as follows: Handbrakes must be applied before recharging the air brake system. Handbrakes must be applied immediately after stopping." SD70Dude As one who uses the handbrake chart and rules on a daily basis at work, I think the current version makes sense. "Handbrakes must be applied before attempting to recharge" is there for obvious reasons. "Handbrakes must be applied immediately after stopping" is not interpreted to mean that all 80 handbrakes must be tightened instantaneously within X-number of seconds after stopping in emergency. It means that the crew must begin the process of applying handbrakes as soon as the train comes to a stop. Before this, the normal first step for an inexperienced crew who finds themselves in this unenviable situation would be to call the Dispatcher and ask for instructions from the Road Foreman of Engines (or whatever your railroad calls them, it's Engine Service Officer on CN). This communication and decision process can take a surprising amount of time, meanwhile the emergency air brake application is leaking off. Applying dozens of handbrakes takes a significant amount of physical effort and time, and many crews and managers alike will look for alternatives before resorting to this torturous task. I myself once fell into that category when I was new and did not understand air brakes as well as I do now. I am not proud of my past ignorance, and I was lucky enough to not work in heavy grade territory when I was new. Later on I ended up working some jobs where I had to apply over 30 handbrakes at once on a regular basis, by myself. It is NOT fun, but it was and is necessary in these situations. I find the handbrake chart to err on the side of caution, which is good, though it does not differentiate between cars with body and truck-mounted air brakes. The handbrake on many cars with truck-mounted air brakes will only apply on the B-end truck, therefore such a handbrake will only provide half the braking effort, while requiring approximately the same amount of physical exertion to apply (ask me how I know). In my quote in blue, I was referencing the order issued by TC after the wreck. When they say handbrakes must be applied immediately after stopping, like you, I interpret that to mean starting the application process immediately after stopping as opposed to waiting for some time before starting. I understand your point that the application takes a lot time. However, this is the rule after the wreck as imposed by the new order. This rule suggests that something was changed from previous rules. It seems that before the change, the rules allowed up to 2 hours after stopping before starting to apply handbrakes. This is indicated by TC's description of what actually happened during the operations on the day of the wreck.
The 2 hour period is for a different scenario, when cars are left unattended on the main track with handbrakes applied, or in a yard with the air brakes left in emergency and no handbrakes applied. In both scenarios the cars are not attached to a locomotive or other air source.
CROR 112 is only for unattended equipment, cars that are attended can still be left in emergency for (in theory) an infinite period of time, provided they do not release or start to move, and as long as they are not on a heavy or mountain grade.
In the 2015 CROR revision unattended is defined as "when an employee is not in close enough proximity to take effective action to stop the unintentional moving of equipment".
It seems obvious now that it is impossible to take effective action to stop a moving train on a mountain grade without using the air brakes, but many interpreted this term to mean that simply standing beside the equipment satisfied the requirement.
The Transport Canada order was issued to eliminate this confusion.
The current CROR 112 can be found here:
https://www.tc.gc.ca/eng/railsafety/rules-tco167-167.htm
OvermodYou can always tell a Government order by its mandatory insistence on impossible operations. It costs little for a twentysomething staff to write up a mandate about 'immediate' application of brakes; it's quite a different thing when a crew with other mandated duties is expected to walk back along a consist tightening brakes that might have been maintained last by agrarian workers in 2006 so they absotively, posilutely apply with full force and effect. (Note the conscious use of a term familiar to twentysomething bureaucratic staff, in a context they might not recognize as unrelatable). You may recall that when you look at the actual number of handbrakes the TC actually calculated itself would be required to bring this about on the train at Field, it worked out to being something like 78, or an appreciable percentage of the train length. I really see a reduced crew getting this done right after an emergency event ... perhaps a repeated one with a dynamiter in the consist ... before they can attend to anything else involved with train handling. It will take some time to apply all those brakes, all completely done before any release and recharge can begin, or really before more than a cursory inspection of the train for the 'cause' of the emergency application can be consciously undertaken ... then more time still to set the train brake sufficiently to hold it and then go back to release all those brakes (and check each to make sure it has fully released at the wheels) to permit the train to actually start downhill under "legal" control. (All this begging the associated question of 'how do you know you have enough application before all the brakes are released' or if the train starts to move while folks are still ratcheting or brakesticking away back there.)
And when the temperature is -28 degrees below zero, and you have to climp up off the ROW and tighten up the brakes and do that 78 times. I think this comes close to a very unreasonable situation to expect anyone to do. I would find the RR management guilty of manslaughter. If the first crew was over the HOS, the Railroad had set up a hobson's choice and the fate of the relief crew was sealed.
SD70Dude,
Thanks for that explanation. So as I understand you, the Ministerial Order issued after the accident was not a change in rules. It merely reaffirmed existing rules because they had been misunderstood in the case of this accident. Apparently that misunderstanding was that it was okay to delay setting hand brakes after the train stopped. And apparently that delay was due to waiting for the second crew to arrive to begin setting handbrakes in order to recover the air.
This indicates that the second crew was only engaged in setting handbrakes for 10 minutes. According to what you were told by someone familiar with the accident, the engineer was on board the engine while the other two crewmembers were out setting handbrakes. So they got 10 minutes into that task and the train began to roll away on its own. The two men setting handbrakes were able to sprint forward and catch the engine before it got away from them.
It was said that upon stopping, the first crew turned up the high pressure retainers. However, it seems to me that the retainers would have been useless with the cylinder packing leaking on most of the cars, as we now know it was. Because the cylinder could not hold pressure due to leaking packing, the high pressure retainer would have no effect. The retainer would retain the set, but the set would leak off through the cylinder packing.
This now all makes sense as the full explanation of what happened. For whatever reason, I can understand the crew not jumping off when the train ran away. If for no other reason, it would be hard to let the train go with the prospect of later explaining that when there might just be some way to save it. And then once you get up to 40-50 mph, it would be really hard to decide whether jumping off would be safer than riding it out.
EuclidSD70Dude, Thanks for that explanation. So as I understand you, the Ministerial Order issued after the accident was not a change in rules. It merely reaffirmed existing rules because they had been misunderstood in the case of this accident. Apparently that misunderstanding was that it was okay to delay setting hand brakes after the train stopped. And apparently that delay was due to waiting for the second crew to arrive to begin setting handbrakes in order to recover the air. From the TSB report: “After an extended period of about 2 hours 45 minutes, a relief crew arrived to replace the crew at Partridge, whose maximum hours of service had been reached. 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.” This indicates that the second crew was only engaged in setting handbrakes for 10 minutes. According to what you were told by someone familiar with the accident, the engineer was on board the engine while the other two crewmembers were out setting handbrakes. So they got 10 minutes into that task and the train began to roll away on its own. The two men setting handbrakes were able to sprint forward and catch the engine before it got away from them. It was said that upon stopping, the first crew turned up the high pressure retainers. However, it seems to me that the retainers would have been useless with the cylinder packing leaking on most of the cars, as we now know it was. Because the cylinder could not hold pressure due to leaking packing, the high pressure retainer would have no effect. The retainer would retain the set, but the set would leak off through the cylinder packing. This now all makes sense as the full explanation of what happened. For whatever reason, I can understand the crew not jumping off when the train ran away. If for no other reason, it would be hard to let the train go with the prospect of later explaining that when there might just be some way to save it. And then once you get up to 40-50 mph, it would be really hard to decide whether jumping off would be safer than riding it out.
The red paragraph as written is very ambiguous - when it says that the crew 'had not yet recovered the air brake pressure from the emergency brake application.
Does this mean that the Engineer had placed his brake valve in the Release position and was attempting to 'pump off' the Emergency application? Or does it mean that the brake valve had been left in emergency and the train started rolling while the emergency application was still applied.
Pumping off a Emergency application on a train that has gone into Emergency on a grade where the only way to secure the train is by the application of hand brakes is a sure fire way to create a runaway when the train has not been secured by hand brakes.
The TSB reports I have read through for this and other incident - they use a rather ambiguous style when stating their 'conclusions' - as if the don't fully believe what they have written and desire elements of 'wiggle room' to be able to refute criticisms of their conclusions.
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