Euclid The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so."
The engineer did not think it was routine. He did not want to leave it running, but was overruled by management. He alludes to that overrule when he was told that the engine later caught fire, and makes some kind of remark that sounds something along the lines of "I told you so."
I read the transcript of the conversations and didn't get the impression that he was over-ruled.
Norm
You are correct. My comment needs clarification; my thinking is that the dispatcher heard of the smoking unit and didn't think that it posed a serious problem. I haven't read any communications between the LE and the dispatcher; a breakdown in communication may have lead to the dispatcher failing to understand the severity of the engine ailment.
NorthWest Guys, I think it is important to note that GE -7 locomotives are known for excessive smoke when loading and throwing oil out the stack (and causing turbo fires) so this may have been considered somewhat of a routine occurrence by those involved, especially due to the age of these units. Catch points ( I think known here as split rail derails) have been standard in the UK almost from the beginning, although IIRC not in dark territory (there was/is little).
Guys, I think it is important to note that GE -7 locomotives are known for excessive smoke when loading and throwing oil out the stack (and causing turbo fires) so this may have been considered somewhat of a routine occurrence by those involved, especially due to the age of these units.
Catch points ( I think known here as split rail derails) have been standard in the UK almost from the beginning, although IIRC not in dark territory (there was/is little).
MM&A has a rule that calls for a response to engine symptoms. That rule would certaily not regard the condition as being routine as the symptoms manifested approaching Nantes. Maybe the day before when just moderately excessive smoke was seen, the condition might have been considered close to normal, but most certainly not when he arrived at Nantes.
gardendance As more and more posts go by I get more and more embarrassed. I thought perhaps LE meant lead engineer, but I thought there was only one engineer, in fact one crew member on the entire train. So what does LE mean?
As more and more posts go by I get more and more embarrassed. I thought perhaps LE meant lead engineer, but I thought there was only one engineer, in fact one crew member on the entire train. So what does LE mean?
Locomotive Engineer as identified in the TSB report.
Never too old to have a happy childhood!
Ask Ricky Gates...
LE = locomotive engineer, as distinguished from a mechanical or chemical, etc. engineer. In many other countries, they are called drivers (translated into the local term, of course).
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Patrick Boylan
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Euclid gardendance jeffhergert As to condition of the engine left running, what appears to be a concern to an outside, casual observer may not be to someone who uses said equipment everyday. That isn't to say the casual observer shouldn't voice a concern, but someone with everyday experience may decide that. while appearing bad, the condition is OK. Conditions can also change. While not an everyday occurrence, it isn't unheard of to have a locomotive fail, sometimes catastrophically, after being inspected. Sometimes after coming out of the shop. I haven't bothered to read much that isn't in trains.com. It seems from that material that casual observers thought the engine had problems. Is there anything that explains why the engineer thought it was the best of the several locomotives available to use? This is my understanding: The engine had exhibited symptoms of moderately excessive smoke over the previous couple days. On the day the doomed oil train ran to Nantes, there was extensive power surging and power dropping that made it difficult to maintain train speed, plus the moderately excessive smoke. On the final uphill grade approach to Nantes, the smoking became very heavy and shifted back and forth from black smoke to white smoke. The engineer thought it would settle down once it was left to idle and cool down from running at full power. But when he left the scene in the taxi, the engine was still smoking heavily and throwing oil out. At that point, the engineer could have set another engine to pump air, but he was out of time, and the company did not want to deal with the problem until morning. The engineer had made the case to the company about the time he left the scene that he did not feel comfortable leaving the engine running in the smoking condition, but he was overruled by others. However, it is important to realize that no others at MM&A knew that that engineer had secured the train with air brakes as a substitute for adequate hand brakes. So the others would not realize the peril of a running engine inadvertently failing.
gardendance jeffhergert As to condition of the engine left running, what appears to be a concern to an outside, casual observer may not be to someone who uses said equipment everyday. That isn't to say the casual observer shouldn't voice a concern, but someone with everyday experience may decide that. while appearing bad, the condition is OK. Conditions can also change. While not an everyday occurrence, it isn't unheard of to have a locomotive fail, sometimes catastrophically, after being inspected. Sometimes after coming out of the shop. I haven't bothered to read much that isn't in trains.com. It seems from that material that casual observers thought the engine had problems. Is there anything that explains why the engineer thought it was the best of the several locomotives available to use?
jeffhergert As to condition of the engine left running, what appears to be a concern to an outside, casual observer may not be to someone who uses said equipment everyday. That isn't to say the casual observer shouldn't voice a concern, but someone with everyday experience may decide that. while appearing bad, the condition is OK. Conditions can also change. While not an everyday occurrence, it isn't unheard of to have a locomotive fail, sometimes catastrophically, after being inspected. Sometimes after coming out of the shop.
As to condition of the engine left running, what appears to be a concern to an outside, casual observer may not be to someone who uses said equipment everyday. That isn't to say the casual observer shouldn't voice a concern, but someone with everyday experience may decide that. while appearing bad, the condition is OK. Conditions can also change. While not an everyday occurrence, it isn't unheard of to have a locomotive fail, sometimes catastrophically, after being inspected. Sometimes after coming out of the shop.
I haven't bothered to read much that isn't in trains.com. It seems from that material that casual observers thought the engine had problems. Is there anything that explains why the engineer thought it was the best of the several locomotives available to use?
This is my understanding:
The engine had exhibited symptoms of moderately excessive smoke over the previous couple days. On the day the doomed oil train ran to Nantes, there was extensive power surging and power dropping that made it difficult to maintain train speed, plus the moderately excessive smoke. On the final uphill grade approach to Nantes, the smoking became very heavy and shifted back and forth from black smoke to white smoke. The engineer thought it would settle down once it was left to idle and cool down from running at full power. But when he left the scene in the taxi, the engine was still smoking heavily and throwing oil out.
At that point, the engineer could have set another engine to pump air, but he was out of time, and the company did not want to deal with the problem until morning. The engineer had made the case to the company about the time he left the scene that he did not feel comfortable leaving the engine running in the smoking condition, but he was overruled by others. However, it is important to realize that no others at MM&A knew that that engineer had secured the train with air brakes as a substitute for adequate hand brakes. So the others would not realize the peril of a running engine inadvertently failing.
Report stated that the LE went on duty at 1330 - he left the scene at 2330. He still had 2 hours of work time available.
A second question about the arrest of three MMA employees.
How would US law handle a situation like the Lac Megantic wreck?
Ed Burns
However, what it important to understand is that the failure to choose a better running engine to keep the air pumped is not the only lapse in judgment here. A far greater lapse in judgment was simply relying on any running locomotive to pump air for maintaining air brakes on the engines for the purpose of securing the train parked on the grade.
That was the fatal flaw, and a clear violation of the securement rule. When the air brakes leaked off, there were only 1/3 of the necessary hand brakse set to hold the train.
The crew change was in fact centered on Megantic. Eastbounds staged at Nantes (west of Megantic)overnight and the American crew got on board there in the morning. Westbounds staged at Vachon, a few miles east of Megantic, and the Canadian crew started from there. As Bruce implied, those two sidings could fit a train without blocking any crossings. Both crews would take rest at the hotel in Megantic overnight before returning to the home terminals the next day.
In the glory days with several trains each way and a largish running trades pool, there was usually a rested crew available to take the train onwards with little delay. The stop downtown was short and tolerable. A marginal short line with only three train pairs a week was forced into a new pattern. When the one or two oil trains a week were added on the off days, the same pattern was used.
John
UlrichWhen I was a kid the crews would change at the station in Megantic, not Nantes.
That is a very old line and not up to modern train sizes. IIRC from media reports at the time the EB train was to big to fit between the grade crossings at Megantic without being broken up, and then there wouldn't be enough room to get the next WB by.
Charlie, as to the criminal proceedings, I think you got it.
Bruce
So shovel the coal, let this rattler roll.
"A Train is a Place Going Somewhere" CP Rail Public Timetable
"O. S. Irricana"
. . . __ . ______
The report gives these numbers. You can clearly see that the train was much more than fully secured with the combination of hand brakes and independent brakes set by the engineer. However once the independent brakes leaked off, there was only 1/3 of the force needed for securement.
Total amount of retarding force needed to hold the train: 146,700 pounds.
Total amount of retarding force produced by hand brakes applied by engineer: 48,000 pounds.
Total amount of retarding force produced by independent brakes: 215,000 pounds.
NP EddieCan anyone tell me what is the status of any criminal charges against the locomotive engineer and the two others arrested?
IIRC they were arrested two months ago, taken to Lac Megantic, charged and released on bail. Trial or preliminary hearing date believe was set for the fall.
Charlie
Chiiliwack. BC
When I was a kid the crews would change at the station in Megantic, not Nantes. Why the change? At that time CP was running some pretty rough looking power too., mostly big MLWs that were on their last miles and looked it.
Can anyone tell me what is the status of any criminal charges against the locomotive engineer and the two others arrested?
We are allowed to figure in engine hand brakes towards minimum requirements in most situations. We are still required to do the securement test, which includes releasing the independent as well as the automatic brake. If the minimum requirement doesn't hold, you tie more until nothing moves during the test. Remember, minimums and guidelines are just that. Nothing is supposed to move during the securement test.
IMO, his securement test was flawed by omitting a release of the independent. Had that been done, it may have shown that more hand brakes were needed.
I found one line in the report puzzling. That car hand brakes usually apply brakes to both trucks, all axles. I assume they checked the cars involved. Depending on what brake equipment is in use, the hand brake may only apply the brake to one truck, half the car. Tank cars and covered hoppers are usually candidates for this type of brake. At least one of our Service Units took this in account when issuing minimum requirements. Those that only applied one truck were considered half a car towards minimum requirements. As a trainman, I once had to tie 13 hand brakes (12 "half" cars and 1 "full" car) to meet a 7 car minimum.
Jeff
dehusman Euclid I suspect that the original reason for keeping a unit running to pump air was to avoid the need to do an air test in the morning. Then because they had this policy in place, by rationalization, it was gradually relied on for securement. I disagree because the purpose was to keep air on the TRAIN brakes and they were released, not providing any braking effort. The rationalization would go something like this: “We know the independents will hold the train. We have the independents because we have air maintained. So, for securement, just set the independents, and set a few hand brakes on the engines and a few cars for extra assurance. That way we are getting double good securement with air and handbrakes (and it saves time of setting handbrakes).” You are assuming that the engineer was counting on the independent brake. If you read the transcript of his converstation the night of the accident, he never mentions the independent brake: (from the transcript of the phone conversations) RJ: I don’t know. How many brakes did you put on? TH: The units, the V.B., and the first car, seven brakes. He is obviously talking about handbrakes (since the VB and first car don't have independent brakes). I interpret that to mean in his mind he wasn't counting on the independent since his comments didn't even mention the independents. It is my interpretation that he wasn't considering the independent as adding any braking power, therefore shutting down the engine was no big deal since all the engines had handbrakes on them. Obviously wrong. The failure in this aspect, in my opinion, was that for whatever reason he was under the impression that the handbrakes on the engine provided "sufficient" braking force and the independent brake didn't materially add to the braking above the handbrake.
Euclid I suspect that the original reason for keeping a unit running to pump air was to avoid the need to do an air test in the morning. Then because they had this policy in place, by rationalization, it was gradually relied on for securement.
I suspect that the original reason for keeping a unit running to pump air was to avoid the need to do an air test in the morning. Then because they had this policy in place, by rationalization, it was gradually relied on for securement.
I disagree because the purpose was to keep air on the TRAIN brakes and they were released, not providing any braking effort.
The rationalization would go something like this: “We know the independents will hold the train. We have the independents because we have air maintained. So, for securement, just set the independents, and set a few hand brakes on the engines and a few cars for extra assurance. That way we are getting double good securement with air and handbrakes (and it saves time of setting handbrakes).”
RJ: I don’t know. How many brakes did you put on?
TH: The units, the V.B., and the first car, seven brakes.
He is obviously talking about handbrakes (since the VB and first car don't have independent brakes). I interpret that to mean in his mind he wasn't counting on the independent since his comments didn't even mention the independents. It is my interpretation that he wasn't considering the independent as adding any braking power, therefore shutting down the engine was no big deal since all the engines had handbrakes on them.
Obviously wrong.
The failure in this aspect, in my opinion, was that for whatever reason he was under the impression that the handbrakes on the engine provided "sufficient" braking force and the independent brake didn't materially add to the braking above the handbrake.
Yes the automatic brakes were released, so they were not providing securement. When I said that I suspected that the original purpose of leaving an engine running to pump air (to avoid a full brake test in the morning) gradually was rationalized to also include securement with air brakes; I meant using the independent air brakes for securement.
The engineer did in fact leave the independent brakes set. While I agree with you that we cannot know for certain that the engineer intended the independents to provide securement, we do know that, in addition to leaving them set after he left, he also conducted his securement test with the independents set.
As you know, that would invalidate the test according to the rules. An invalid test is no test. So because the engineer performed a test that he believed to be valid (as he attested), the only purpose for leaving the independents set during the test would be to include the independents as part of the securement.
From this, I conclude that the engineer did intend the independent brakes to provide securement. Further supporting this conclusion is the fact that he did not apply enough hand brakes to achieve securement. Although, I suppose it is possible that the handbrake deficiency was simply an error. Leaving the independents set during the test might have also been an error. If those two errors were made, it does allow for the possibility that the engineer placed no reliance on air brakes to secure the train.
In any case, when I suggested this rationalization mentioned above, I was not confining it to the engineer of the runaway oil train. Other engineers reported similar practice of securement. It is also possible that the engineer of the runaway train had performed the same faulty securement many other times. I think it was a mutually reinforced pattern that grew less stringent in the securement objective in order to save time and expense.
Overmod gardendance Portable derails sound a lot like the chocks I mentioned a few posts back. ... What you are in essence suggesting is that an engineer on 'short time', expected to be on critical duty after a known rest interval, should walk all the way back to the rear of the consist, presumably lugging the derail at least some part of that way -- or have the cab take him as far down as possible? And then either walk back or have his cab pick him up at the closest point of approach?
gardendance Portable derails sound a lot like the chocks I mentioned a few posts back.
Portable derails sound a lot like the chocks I mentioned a few posts back.
...
What you are in essence suggesting is that an engineer on 'short time', expected to be on critical duty after a known rest interval, should walk all the way back to the rear of the consist, presumably lugging the derail at least some part of that way -- or have the cab take him as far down as possible? And then either walk back or have his cab pick him up at the closest point of approach?
You're mixing up me and blue streak 1. I didn't suggest that we use derails, and I didn't even suggest that we use chocks. I only asked what a chock might have done, subsequently blue streak 1 suggested portable derails and I commented that his suggestion's not much different from a chock.
Dave H. Painted side goes up. My website : wnbranch.com
I am wondering if MMA Officials ever performed securement tests as a part of their efficiency testing? I know the officials of my company do such tests and employees have been disciplined for failures. Additionally my company's policy is that engines are not part of the count toward what is required to secure the train. On grades the minimum number of hand brakes to applied to the train is 30% and more if necessary.
If efficiency testing was done, and this was the accepted permissible securement, the fault lies with accepted MMA practices. If efficiency testing was done and this form of securement was the basis for assessed discipline, then the LE never got the word that this was not an acceptable practice.
While train crews can complain of officials performing efficiency tests as Weed Weasels - efficiency testing is the only method of supervising a geographically disbursed and moving work force in the correct performance of their duties.
I suspect that the original reason for keeping a unit running to pump air was to avoid the need to do an air test in the morning. Then because they had this policy in place, by rationalization, it was gradually relied on for securement. The rationalization would go something like this: “We know the independents will hold the train. We have the independents because we have air maintained. So, for securement, just set the independents, and set a few hand brakes on the engines and a few cars for extra assurance. That way we are getting double good securement with air and handbrakes (and it saves time of setting handbrakes).”
Then when it came to the case of the one locomotive running with an engine problem, the reasoning just jumped back to the original premise of leaving an engine running to pump air to avoid the morning air test. It would be just more convenient rationalization to leave out the second reason of keeping the independents charged to hold the train overnight. With this rationalization, the risk of an engine failure overnight would only mean that they would have to do a full air test in the morning. And that was a small risk they were willing to take.
In this type of thought process, it appears that the engineer never even considered the risk of losing the independent brakes if the engine happened to die. The procedure had just become habit and it always worked before.
What I still do not understand is why Harding left only the head-end unit live and shut down the other three (or four) that were presumably in good condition (or were they?). Common sense would have said to keep a good, non-smoking, unit life and shut down the one belching oil and smoke and sparks!
That, and not securing enough hand-brakes
My B&M experience would certain have caused me to do both had I been the engineer. Any railroader take issue with that?
If RRs do not want a derail on main lines then assuming a 2 man crew.
1. Locate a split rail derail at a down hill siding switch.
2. Any cars or train left on siding would be located near the downhill siding switch and derail. The derail would be opened.
3. For a train coming down hill that will be secured at that location that train enters the siding and stops short of any cars /rain if present or just short of the derail.
4. Conductor would close upper siding switch if possible or would ride down hill on the last securement car. He would then set hand brakes going forward toward the locomotive(s).
5. If push pull test OK secure loco(s) then crew would go off duty otherwise more car hand brakes would be set until satisfactory push pull.
6. An hill train would either enter siding at down hill side or proceed to uphill switch. Conductor would reverse siding switch and train would back down to either derail or short of any train / cars.
6a. Uphill conductor would close siding switch and open derail.
7. If train goes past up hill switch then backs down and if clears main then engineer would align switch to main otherwise switch would remain reversed while conductor sets hand brakes..
8. Securement would be same and once completed crew could go off duty.
9. Non standard sidings such as one switch or hump in middle would need some modifications to this procedure. Maybe split rails at both ends ?
10. Last cross country trip noted split rails on many spurs and very few sidings.
10 This is a last ditch item to stop a run away that is happening not to relieve crews of proper securements
11. Comments ?
After reading that full transcript I can better understand the conversations between the engineer and his supervisor, and the reasoning behind their initial conclusion that the big fire in Lac Megantic was not the MM&A oil train that the engineer had parked at Nantes. After being comforted by that conclusion, it must have been quite a shock to find out that it was the oil train.
Although I am not clear on why the engineer was asking his supervisor if there were any MM&A oil cars in Lac Megantic. Maybe he was concerned that parked oil cars might get involved with the fire even though it was caused by a pipeline rupture (they thought).
In any case, it was sure an Alfred Hitchcock moment when the supervisor told the engineer that it was his train that rolled down and caused the fire.
17 minutes of Tom Harding on the phone.
http://www.cbc.ca/news/canada/montreal/lac-m%C3%A9gantic-train-engineer-s-emergency-calls-released-1.2743201
With a significant difference,
An "adequate" number of chocks to hold the train (leaving aside how many chocks might be required or of what material they'd have to be made -- we've had some discussions about this on the forums before) could be deployed at the forward end of the train, where the handbrakes are being set.
For a portable derail to be effective, it would have to be placed at the downhill end of the consist, presumably so that not a single car could break loose and 'roll down'.
We just had a comment about single-man crews and the time involved in walking a hazmat consist stopped in multiple-track territory. What you are in essence suggesting is that an engineer on 'short time', expected to be on critical duty after a known rest interval, should walk all the way back to the rear of the consist, presumably lugging the derail at least some part of that way -- or have the cab take him as far down as possible? And then either walk back or have his cab pick him up at the closest point of approach?
As it turns out, this would in fact have been a "19th factor" preventing the Lac Megantic runaway. But as a daily operating procedure? Let alone the fun involved in retrieving the derail at the start of the next part of the run... cab to near the rear of the consist, retrieve the derail, back up to the front... and as noted earlier, what fun if someone forgets the details of retrieving it and the opposing movement encounters it at speed...*
There's also a safety question -- or the perception of a safety problem, perhaps by hostile groups with agendas -- regarding the intentional derailing of tank cars loaded with volatile material as a matter of standard operating procedure.
*Remember this was 'dark territory' so even shunting across the rails won't reveal the presence of the derail, and I suspect MMA had no 'proximity alert' system (is it QNS&L that has this?) that could respond to a transponder signal from a derail as if it were another locomotive. I do suspect that we'll in fact be seeing calls for portable derailing 'systems' for stopped oil trains, and perhaps brainstorming on how to make them as 'idot' proof as possible [/sarc] would be a worthwhile discussion in its own thread.
I believe you will find, on re-reading the material, that Harding thought the SQ (or some other police) had told him the train was still at Nantes, and the supposition was that a natural-gas pipeline had caused the fire.
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