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NTSB: Canadian National failed to warn train before derailment

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Posted by beaulieu on Friday, February 17, 2012 12:44 PM

As far as I am aware all the railroads do it the same way, just that the others have better internal procedures. And better communications systems.

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Posted by zugmann on Friday, February 17, 2012 12:38 PM

Do you believe that Bucyrus, or are you just trolling? 

 

Sometimes I can't tell with you.

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

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Posted by Anonymous on Friday, February 17, 2012 12:30 PM

petitnj

Interesting but the CN dispatcher phones put you on hold. You shouldn't get a busy signal!.

We need more railfans with RR radios, red flags and fusees.

BTW if you see this sort of thing. Send someone 1 mile on either side of the washout and place a fusee or red flag or wave your hands wildly as a train goes by. All of those are signals to stop.

Yes that is what Kate Shelley would have done in the age of self-reliance and rugged individualism.  But this is the Decade of Gotcha!

So if you were to take that responsible course today of flagging the train, you would probably get an unexpectedly speedy response from Homeland Security, the FBI, the local police, and the railroad police—all reading you your rights—as the train piled up in the background. 

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Posted by schlimm on Friday, February 17, 2012 11:55 AM

Pretty clearly the problem is in CN's communication system and over-centralization.  Emergency phone calls should not have to go to Montreal and then to Homewood.for action (Perhaps the Homewood folks resent control in Montreal?).  Or if CN insists on this system, Montreal should be capable of communication to loco crews directly.  17 minutes and nothing done.  The response took 21.

 

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Posted by petitnj on Friday, February 17, 2012 7:37 AM

Interesting but the CN dispatcher phones put you on hold. You shouldn't get a busy signal!.

We need more railfans with RR radios, red flags and fusees.

BTW if you see this sort of thing. Send someone 1 mile on either side of the washout and place a fusee or red flag or wave your hands wildly as a train goes by. All of those are signals to stop.

 

 

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Posted by BaltACD on Friday, February 17, 2012 7:19 AM

First - I have no idea of any procedures that CN may or may not have had in place when this event happened.

With my carrier - the Chief Dispatchers desk for each territory has a physical 'Emergency Line' telephone - in addition to the line ringing on the computerized Avtech telephone system, the old dial style telephone with a loud ringer goes off.  Instructions are that the CTD will drop any other business or call they may be handling and answer the Emergency Line - IF the CTD is away from the desk for some reason, since the phone can be heard by every Dispatcher in the office - the nearest will answer it.  The Emergency Line number is the pre-programmed number that the company police center uses and all outside parties are directed to call it by the signs placed on both sides of every road crossing as well as the police center's handling with any local emergency personnel (police, fire etc.).  The Emergency Line cannot be used to place a outbound call and has no other use than for EMERGENCY COMMUNICATION.

The ringing of the Emergency Line is not to be trifled with and it along with all other telephone lines used by contract personnel in the dispatchers office are on time stamped and recorded line.

Paul_D_North_Jr

Old point:  "CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn."  Bet that's not the first time that happened !  More likely - a common if not everyday occurrence, which was routinely 'blown off' or simply ignored by upper management when called to their attention or when complaints were made - all in the name of 'efficiency' by having less than an adequate number of people on duty, of course.  When will they ever learn ?

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Posted by LWales on Thursday, February 16, 2012 10:37 PM

As a Rockford, IL resident, I will say that you do have most of the facts straight--the washout happened about an hour before the train got to the crossing. There were severe thunderstorms that passed through the area, dropping a large amount of rain in a short time. A retention pond from a nearby subdivision filled up and then failed, sending a large amount of water down toward the parallel Union Pacific and Canadian National tracks at the Mulford Road crossing.

This exact spot had been the site of washouts--just like this one--that occured back in 2006 and then around 2000. The potential for a problem at this site was well known to the railroad and to local officials, because it had happened before.

Local residents informed the police, who did come out to the crossing and filmed the washout with his dashboard camera, showing the culvert washed out and the tracks suspended for about 20 feet just west of the Mulford Road crossing. The deputy was the one who called the CN to warn them of the situation, but the call went to Montreal and it took them too long to get in touch with the dispatchers in Homewood, IL. I think he called about 20 minutes before the train got there, but I haven't read the final report. The officer left the scene before the train got there (the Freeport Sub only runs one scheduled freight each direction daily) so it wasn't like there are frequent trains on the line.

The oddest thing to me is the two locos and 50 some cars made it over the washed out track before the train derailed. Although it was right about sunset--the large amount of standing water near the tracks at the location the crew should have seen something wasn't right as they approached the crossing.

Lance

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Posted by Paul_D_North_Jr on Thursday, February 16, 2012 8:31 PM

Two new points:

1.  It seems that both locomotives and many loaded tank cars - about 36 + 20 = 56 cars, or half the train - made it over the washout before the rail broke and caused the derailment - simply amazing ! See this transcript of the NTSB's interview/ deposition of the conductor 2 days later at:  http://dms.ntsb.gov/public%2F48000-48499%2F48053%2F460268.pdf  

2.  Despite all the rain and flooding that day and night, the train crew apparently didn't see any need to go slower or stop.  See this transcript of the NTSB's interview/ deposition of the engineer 2 days later at: http://dms.ntsb.gov/public%2F48000-48499%2F48053%2F460281.pdf 

I found these interviews from the Rockford Register Star newspaper's links to them here: http://www.rrstar.com/news/trainderailment/x13287670/Train-derails-National-Transportation-Safety-Board-releases-information 

Old point:  "CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn."  Bet that's not the first time that happened !  More likely - a common if not everyday occurrence, which was routinely 'blown off' or simply ignored by upper management when called to their attention or when complaints were made - all in the name of 'efficiency' by having less than an adequate number of people on duty, of course.  When will they ever learn ?

- Paul North.   

"This Fascinating Railroad Business" (title of 1943 book by Robert Selph Henry of the AAR)
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Posted by schlimm on Thursday, February 16, 2012 4:20 PM

from the Register-Star:  The initial 911 calls regarding the washout came about an hour before the derailment occurred, where the CN tracks cross South Mulford Road. Despite delays in finding an available law enforcement officer to investigate, Winnebago County Sheriff’s Sgt. Aaron Booker notified the railroad of the damage 20 minutes before the derailment.

CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn.

Only at 8:40 p.m., about four minutes after the derailment, was contact made.

In transcripts of interviews done in Rockford in the days after the derailment, NTSB investigator Russell Gober comments on the 17-minute effort during conversations with multiple individuals tied to the wreck.

“We know that you guys were trying. But your people made three attempts which would, on the third attempt ... if Homewood had answered, there would have still be five minutes before the wreck happened,” he said during an interview with Julia Vespoli, a CN police employee.

Investigators also focused on CN’s procedure to warn its trains of inclement weather. Two hours before the derailment, forecasting service AccuWeather issued a severe flood warning for the Freeport area, including Rockford. The alerts come to the Homewood dispatch center via a dedicated printer equipped with an alarm bell to alert staff of the weather report.

That night, however, it’s unclear when the report was delivered to Darnell Parker, the dispatcher in charge of the rail lines around Rockford. Parker never relayed the report to the CN train as it approached Rockford. It’s unclear what effect the warning would have had on the train, as CN procedures only call for engineers to be cautious in light of a flash flood warning, not to stop the train.

“We have some terrible mix-ups in communications between the dispatchers and the real world, it seems,” Gober said."

Understatement of the year.

 

 

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Posted by Anonymous on Thursday, February 16, 2012 3:52 PM

This is the preliminary report.  The final has not yet been released:

http://www.ntsb.gov/news/events/2012/cherry_valley/index.html

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Posted by BaltACD on Thursday, February 16, 2012 3:37 PM

Does anyone have the link to the actual NTSB report?

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Posted by Anonymous on Thursday, February 16, 2012 2:23 PM

n012944
Now maybe I am missing it, but no where in the report does it say who discovered the washout.

"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"

Edit....

After doing a little more research, it was not the CN who discovered the washout.

http://www.rrstar.com/news/trainderailment/x1161121396/In-Sundays-paper-Efforts-to-warn-train-failed

You are correct about that.  Thanks for finding that link to the reporting details.  I thought I had read somewhere that CN had discovered the washout an hour before the derailment, but after my last post, it went back to double check the NTSB report, and as you point out, the report does not say that.  So I am reviewing what was said where.

 

I see that the news article linked to the first post here says, “CN knew for an hour about the washout along the tracks near Rockford, but failed to notify a freight train in time to prevent a deadly derailment in 2009, the NTSB determined today.”

 

However, this statement is apparently untrue in view of article you linked.  According to that article, the CN was informed about the washout 20 minutes before the derailment. 

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Posted by n012944 on Thursday, February 16, 2012 1:14 PM

Bucyrus

 

 n012944:

 

 

 schlimm:

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. 

 

 

 

Funny I read it different.  The report said that the washout was discovered one hour before the incident, which is very different than the CN being informed one hour before.  I would like to see a full report, with all the conversations and times

 

 

Yes, but the report says that it was CN that discovered the washout one hour before the derailment. 

So I would say that means exactly the same thing as saying that CN was informed about the washout one hour before the derailment. 


 

Now maybe I am missing it, but no where in the report does it say who discovered the washout.

 

"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"

 

Edit....

 

After doing a little more research, it was not the CN who discovered the washout.

 

http://www.rrstar.com/news/trainderailment/x1161121396/In-Sundays-paper-Efforts-to-warn-train-failed

 

 

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Posted by Anonymous on Thursday, February 16, 2012 1:02 PM

~

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Posted by n012944 on Thursday, February 16, 2012 12:52 PM

schlimm

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. 

 

Funny I read it different.  The report said that the washout was discovered one hour before the incident, which is very different than the CN being informed one hour before.  I would like to see a full report, with all the conversations and times

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Posted by schlimm on Thursday, February 16, 2012 11:44 AM

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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Posted by BaltACD on Thursday, February 16, 2012 7:11 AM

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.

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Posted by Anonymous on Wednesday, February 15, 2012 10:21 PM

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.

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Posted by schlimm on Wednesday, February 15, 2012 10:11 PM

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."

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Posted by Chris30 on Wednesday, February 15, 2012 9:51 PM

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?

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Posted by williamsb on Wednesday, February 15, 2012 8:51 PM

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!

 

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Posted by schlimm on Wednesday, February 15, 2012 6:46 PM

BaltACD: You do realize the CN (IC) derailment near Rockford was because of a track washout?  The road crossing was unfortunately nearby.

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Posted by Anonymous on Wednesday, February 15, 2012 6:43 PM

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?

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Posted by BaltACD on Wednesday, February 15, 2012 4:59 PM

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?

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Posted by petitnj on Wednesday, February 15, 2012 4:37 PM

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.

 

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Posted by Paul_D_North_Jr on Wednesday, February 15, 2012 2:40 PM

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. 

  First point understood and taken. 

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 ?

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Posted by Anonymous on Wednesday, February 15, 2012 1:44 PM

I understand that somebody reported the washout to the railroad police.  All I want to know is what they did about it. 

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Posted by beaulieu on Wednesday, February 15, 2012 1:33 PM

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.

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Posted by Anonymous on Wednesday, February 15, 2012 1:02 PM

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. 

 

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Posted by beaulieu on Wednesday, February 15, 2012 12:52 PM

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.

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