http://www.chicagotribune.com/news/local/breaking/chi-ntsb-canadian-national-failed-to-warn-train-before-derailment-20120214,0,2579556.story
No way to run a railroad.
C&NW, CA&E, MILW, CGW and IC fan
“There were missteps and miscommunications, procedures not followed and poor decisions,” NTSB Chairman Deborah A.P. Hersman said at the hearing in Washington, D.C. “There were multiple points where this catastrophe could have been averted but it was not.”
Putting aside the lost of innocent bystanders' lives, the CN apparently doesn't look after its train crews very well either. I wonder what, if any reaction there would be, if any of the crew had been killed in a derailment that should not have occurred.
Reaction from the public if the train crew alone had been killed or reaction from other railroaders if the train crew were the only fatalities?
Or are you wondering if there would have been as much negative press if only the crew dies?
I would suggest that the only reason it made headlines this late is because of the civilian fatalities.
If the crew had died, and been the only ones, then it would just be a few more numbers in the annual FRA report.
I can feel empathy for the survivors, all they were doing was waiting for a train to pass, simply in the right place at the wrong time.
Hope they collect every single dime.
23 17 46 11
One can't reasonably draw sweeping conclusions from a single incident, however tragic. CN apparently acknowledges fault and wrong doing, but I don't think this terrible accident is indicative of a "we don't care" attitude" at CN. Surely they've changed their procedures and have fired those who are responsible. CN isn't the only railorad to have had an accident, and almost all accidents are due to someone's error or oversight at some point. Obviously this is tragic for those who were killed, and their families are entitled to every last dime of that 36 million.
For the railroad to have known for the washout for an hour without warning the train, it seems like quite the candy-coated explanation to say that, “There were missteps and miscommunications, procedures not followed and poor decisions.” Do they think the public is that stupid?
I may have not stated what I meant clearly. Putting aside the bystanders, it seems that a railroad has a real problem when it has information that affects the safety of its trains and crews but has a system that doesn't reliably inform them of the danger, even with ONE hour to do so. It isn't like it was a matter of seconds or minutes or that radio or cellphone technology wasn't available. Kate Shelly managed 130 years ago to run in the dark to stop a CNW train from disaster with a damaged bridge and help rescue a crew. I would think CN (IC) employees, in the US at least, should have concerns.
You hear about incompetence everywhere...CN certainly does not have the monopoly on that. They draw from the same labor pool everyone else does, so they too get their share of bad apples. However one case doesn't necessarily point to a system wide problem nor does it suggest that nobody at CN cares and that they willfully put their train crews in danger. Clearly someone didn't do his/her job...mistakes will happen as long as people remain imperfect. The safety board's conclusions were obviously right on the money...failure to inform the train crew of the impending danger would most certainly be a "mis communication"..or more precisely, a non communication...and you'd have to believe that unless you've got evidence that someone intentionally did not advise the crew.
schlimm I may have not stated what I meant clearly. Putting aside the bystanders, it seems that a railroad has a real problem when it has information that affects the safety of its trains and crews but has a system that doesn't reliably inform them of the danger, even with ONE hour to do so. It isn't like it was a matter of seconds or minutes or that radio or cellphone technology wasn't available. Kate Shelly managed 130 years ago to run in the dark to stop a CNW train from disaster with a damaged bridge and help rescue a crew. I would think CN (IC) employees, in the US at least, should have concerns.
I would like to see the report itself, not just the quotes in the newspaper. What I would like to know is whether the call went to Homewood, IL or to Montreal, PQ. If it went to Montreal I can better understand a degree of delay. Nevertheless if CN went to centralized notification they should have had a better system for disseminating the information to their people who could do something with it. Several other Class Is had similar incidents when they went to Centralized Emergency call-in systems, though I am not sure if any others involved fatalities.
Centralization.
Fewer people doing more. But when is fewer "not enough" and more "too much"?
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
UlrichYou hear about incompetence everywhere...CN certainly does not have the monopoly on that. They draw from the same labor pool everyone else does, so they too get their share of bad apples. However one case doesn't necessarily point to a system wide problem nor does it suggest that nobody at CN cares and that they willfully put their train crews in danger. Clearly someone didn't do his/her job...mistakes will happen as long as people remain imperfect. The safety board's conclusions were obviously right on the money...failure to inform the train crew of the impending danger would most certainly be a "mis communication"..or more precisely, a non communication...and you'd have to believe that unless you've got evidence that someone intentionally did not advise the crew.
According to the article, the NTSB has said:
“There were missteps and miscommunications, procedures not followed and poor decisions.”
That sounds a lot more like a system failure than one person making a mistake.
Can someone find and link the report so we can understand what actually happened?
Not necessarily...one person can do all three...happens all the time but fortunately not with such devastating consequences.
zugmann Centralization. . . . Fewer people doing more. But when is fewer "not enough" and more "too much"?
- Paul North.
Bucyrus [snipped] Can someone find and link the report so we can understand what actually happened?
Note this excerpt from it: "A synopsis of the NTSB report, including the probable cause, conclusions, and a complete list of all the safety recommendations, is available at: http://www.ntsb.gov/news/events/2012/cherry_valley/index.html.
The NTSB's full report will be available on the website in several weeks."
If you go to that latter link. it looks like a pretty comprehensive report even now:
Cherry Valley, IllinoisJune 19, 2009
NTSB Number: RAR-12-01
Thanks for posting that link Paul,
After reading it, the cause indeed sounds like a systemic problem with CN, as opposed to a mistake by one person. After all, the remedies recommended by the NTSB are all about new systems and programs. It says nothing about one person making a mistake.
All the report says about the possible prevention of this derailment by notifying the crew is that the police emergency communication system was inadequate. Not only does that sound systemic, but also it makes me wonder what it even means. Did somebody leave some wires unconnected?
The report sounds to me like it is blowing smoke to obfuscate on the failure of notification to prevent the derailment.
The report seems to go into an awful lot of detail about the tank car design, and yet all they have to say about the one possible prevention of this derailment is that a communication system was inadequate.
It's almost impossible to get it exactly right. The minute you hire enough hands to take care of increasing sales, sales drop and you've got people sitting around and under employed. Conversely, the minute you adjust your workforce in response to flagging sales, things pickup and you're caught without enough people to do the work. I've never had it balanced exactly right for more than a few minutes. I'm also shorthanded or have too many people available for the work available.
Bucyrus Thanks for posting that link Paul, After reading it, the cause indeed sounds like a systemic problem with CN, as opposed to a mistake by one person. After all, the remedies recommended by the NTSB are all about new systems and programs. It says nothing about one person making a mistake. All the report says about the possible prevention of this derailment by notifying the crew is that the police emergency communication system was inadequate. Not only does that sound systemic, but also it makes me wonder what it even means. Did somebody leave some wires unconnected?
No markings at the crossing yet. The people handling the call failed to promptly notify the Dispatcher. (Note: the call went to Railroad Police, not civil) .
The report sounds to me like it is blowing smoke to obfuscate on the failure of notification to prevent the derailment. The report seems to go into an awful lot of detail about the tank car design, and yet all they have to say about the one possible prevention of this derailment is that a communication system was inadequate.
The statements about Tank Car design are about mitigating the severity of the accident. If the Tank Cars had been designed and built to the same standards as those for handling TIH, then likely one or none would have breached, rather than 17.
I agree that the tank car design was certainly relevant to the consequences of the derailment, but my point is about how much detail the report offers about tank car design and every other conceivable minutia, while glossing over the failure of the emergency system that would have prevented the wreck.
To be consistent, considering the way they dismiss the failure of the emergency system, I would not expect any details about the mechanics of tank cars.
Perhaps unbiased objectivity is not to be expected from the NTSB.
Wait for the final report.
I will say that it is easier for the NTSB to point to specifics about the Tank Car design, rather than trying to describe an ideal phone/Internet/Data system to alert the correct Dispatcher and provide the necessary location and details. The lack of Crossing markings would make it more difficult to identify the correct area, as the Dispatcher might or might not be familiar with the highway crossings.
I understand that somebody reported the washout to the railroad police. All I want to know is what they did about it.
beaulieu Wait for the final report. I will say that it is easier for the NTSB to point to specifics about the Tank Car design, rather than trying to describe an ideal phone/Internet/Data system to alert the correct Dispatcher and provide the necessary location and details. The lack of Crossing markings would make it more difficult to identify the correct area, as the Dispatcher might or might not be familiar with the highway crossings.
As to the rest - OK, but in the meantime: Why can't the NTSB use the systems, procedures, and markers of other similar-sized Class I's as "best practices" in the industry that should be implemented and emulated, at least until a better system is thought up and rolled-out ? The plaintiffs' lawyers will certainly try to do that, to establish a "standard of care" in the industry that could have and should have been followed, and which likely would have prevented the tragedy.
Are the NTSB and the unenlightened members of the industry to remain stupefied into inaction by "the perfect is the enemy of the good" syndrome once again ?
In recent years CN has issued RULE W warnings (severe weather) to trains along its subdivisions.
Partial Quote:
Flash Flood Warnings– At locations specified by the RTC, timetable or Operating Bulletin, trains will operate prepared to stop short of obstructions.
I believe they have been working hard to get these warnings out and have trains slow down.
Historically the biggest problem in communications between railroads and outside parties is determining where HERE is.
In it's simplest form - Railroads are defined by milepost. The rest of the world is defined by hundred block or where the Jiffy-mart is. Two different languages.
The carriers efforts in placing DOT crossing identification plates at each crossing has had a beneficial impact in bridging the gulf between these two languages, however, in many cases there is still a lot of territory where confusion can reign - when trying to identify a location that is not in the immediate vicinity of a road crossing that has DOT identity plates. A second area of confusion is where multiple carriers are operating parallel to each other through a location - the outside party may only notify one carrier and that may not be the correct carrier (carriers have become more knowledgeable about this and in addition to notifying the party to contact the other carrier(s) will also contact the other carrier(s)) - Notification of the additional carrier(s) takes time - and in many cases time may be a priority.
Anecdote from reality - Carrier was notified by Outside Party of a truck being 'hung up' on a crossing (not specified) in a named city area. The named city area was notified by the carrier of what the OP reported, in the interim the carrier held traffic out of the area. The named city area after conducting their 'investigation' one hour later reported there were no trucks hung up on any crossing in the named city area. Traffic was released. 15 minutes later the first train released reported they had run through a loaded moving van at a crossing 1/10th of a mile outside the defined limits of the named city.
Where is HERE?
Never too old to have a happy childhood!
I have not heard that this washout was discovered and reported by an outside party. From what I read, it was CN that discovered the washout. How did they discover it? Who discovered it?
BaltACD: You do realize the CN (IC) derailment near Rockford was because of a track washout? The road crossing was unfortunately nearby.
If you are out taking pictures of trains and want to know the exact location you are at, check the rr crossing sign, it has the exact rr location and who to call in case of emergency. It is on all the crossings in Canada and according to item #5 in the report should have been there but wasn't.
5. " Had the required CN grade crossing identification and emergency contact information been posted at the Mulford Road crossing, the railroad would likely have been notified of the track washout earlier and the additional time may have been sufficient for the rail traffic controller to issue instructions to stop the train and prevent the accident. "
Regular peple using the crossing probably would not know this but police and emergency workers should. Something as simple as a missing tag was probably a major cause of the communication failure.
At least CN paid the $36 M which was deserved and didn't try and get out of it through some technicality as CP did with their derailment several years ago at Minot, ND. There was a death due to chlorine gas ( I think ). An award of $3 or $4 M was awarded and CP appealed it was exhorbitant and they were exempt and won!
The initial report from the NTSB is very clear and places almost all of the blame on CN as a whole, not any one indivdual. If you sum up the report, the NTSB basically calls the CN incompetent in regards to their safety procedures.
From the new recommendations section of the report:
"12. Implement a program consistent with principles of safety management systems to periodically test all aspects of your internal emergency communication system to ensure that personnel are familiar with the system's operation and that emergency notifications can be communicated immediately to any chief dispatcher or rail traffic controller in your system."
I don't believe that any railroad running ethanol trains through mass populated surburbs of a large city should have to be told to implement a safety program. Does anybody (FRA?) check / verify safety procedures for any / all railroads?
CC
The primary cause of the accident are these related factors:
"The National Transportation Safety Board determines that the probable cause of the accident was the washout of the track structure that was discovered about 1 hour before the train's arrival, and the Canadian National Railway Company's (CN) failure to notify the train crew of the known washout in time to stop the train because of the inadequacy of the CN's emergency communication procedures."
I thought it interesting that the report mentioned something to the effect that if CN had the phone number posted at the crossing, somebody probably would have called about the washout earlier, and thus CN would have had more than just an hour to notify the crew.
I am fully aware of that - what I am emphasising it that when outside parties - be they police departments or ordinary citizens - report something, anything to a railroad the hardest and most crucial part of the conversation is to understand where HERE is. Locals know their areas in relation to local landmarks. Railroads know their area in relation to mileposts. They are two different languages that MUST be meshed into finding the CORRECT point of the incident - crossing incident, bridge strike, washout - any incident that concerns both parties.
schlimm BaltACD: You do realize the CN (IC) derailment near Rockford was because of a track washout? The road crossing was unfortunately nearby.
But the point is that the CN was informed of the washout, where, etc. ONE HOUR before the incident and their system failed to inform the train crew.
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