RBMN Tamaqua Derail?

[Backshop]

I'm sure the R&N knew about it.

[steve-in-kville]

Not sure where I read this, but it was a string of empties parked on a side rail. Nothing was under power.

[MMLDelete]

steve-in-kville

it was a string of empties parked on a side rail

They were bored. Clearly, this is a ploy to get attention.

[steve-in-kville]

Lithonia Operator

 

 

steve-in-kville

it was a string of empties parked on a side rail

 

 

They were bored. Clearly, this is a ploy to get attention.

 

 

Right! I obviously missed that angle.

[zugmann]

Better watch it - if that derailment gets too much attention - they'll be charged an amusement tax! 

 

 

[BaltACD]

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s).

[mudchicken]

Something like that can lead to fatal consequences. (Saw that here in CO. Shortline was the unfortunate victim of that [Kyle RR near Arriba, CO   1986])

https://www.upi.com/Archives/1986/08/27/A-freight-train-collided-head-on-with-14-railroad-cars/4594525499200/ 

[tree68]

BaltACD

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s)..

Like a certain 13 year old in Utica, NY...

OTOH, I looked at the topo for that area, and it doesn't appear there's much of a grade, not that it takes much...

[zugmann]

Sounds like a boring ol' derailment that someone (non-RR) stumbled upon and made a big deal about.   

[BaltACD]

tree68

 

BaltACD

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s).. 

Like a certain 13 year old in Utica, NY...

OTOH, I looked at the topo for that area, and it doesn't appear there's much of a grade, not that it takes much...

The way they are derailed - motion was involved - where the were when they started and where they derailed are two different locations.  Today's roller bearing cars can move on lesser grades than the plain bearing cars of yesteryear.

[tree68]

BaltACD

...motion was involved...

Agreed.  This wasn't the result of a rail rolling over while they sat there.

Like I said, it doesn't look like there's much of a grade, but it doesn't take much.

[MMLDelete]

BaltACD

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s).

 

Would that cut have likely been left there with air in the train line?

If there was NO air in the train line, the brakes would be applied, right? Because the reservoirs' air would apply them, right?

The reason I ask is because you said someone must have released the handbrakes. But I'd think they still wouldn't roll, because of the reservoirs.

Are handbrakes used because the pressure in the reservoirs will inevitably leak out over time?

When I see a cut of cars sitting somewhere, is there air in the brake pipe? Or has all the air, both in the brake pipe and the reservoirs, been released?

When the train that had those cars set them out there, what was the routine regarding brakes? (assuming it was done by the book)

Help me out here, guys.

Am I hopelessly confused about railroad brakes?

[jeffhergert]

Lithonia Operator

 

 

BaltACD

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s).

 

 

 

 

Would that cut have likely been left there with air in the train line?

If there was NO air in the train line, the brakes would be applied, right? Because the reservoirs' air would apply them, right?

The reason I ask is because you said someone must have released the handbrakes. But I'd think they still wouldn't roll, because of the reservoirs.

Are handbrakes used because the pressure in the reservoirs will inevitably leak out over time?

When I see a cut of cars sitting somewhere, is there air in the brake pipe? Or has all the air, both in the brake pipe and the reservoirs, been released?

When the train that had those cars set them out there, what was the routine regarding brakes? (assuming it was done by the book)

Help me out here, guys.

Am I hopelessly confused about railroad brakes?

 

When cutting away they should, and probably did, allow the brake pipe to "dynamite" putting the air brakes at their highest braking force.  However, the brake cylinders can leak off over time.  Some may hold for weeks, maybe months.  Others may only hold for minutes or hours.  That's why hand brakes are applied.

If someone had malicious intent and knew enough to release the hand brake, there's a good chance they would know about bleeding off the brake cylinders.  

Jeff

[tree68]

jeffhergert

If someone had malicious intent and knew enough to release the hand brake, there's a good chance they would know about bleeding off the brake cylinders.  

Even if the stunt wasn't malicious as such (ie, they didn't intend to cause damage, but just wanted to see the cars roll), the brakes may well eventually bleed off and away we go.  Those cars are probably on their last legs, used  for ballast, etc.

The young man who cut the car loose in Utica probably didn't know any better.  As an aside, I think the Suzy-Q uses a skate there now.

[MMLDelete]

Thanks, guys.

In the Lac Megantic tragedy, did the engineer leave air in the train? Isn't that called "bottling air," and against rules?

With like 80 sets of brakes on those tank cars, if the engines had uncoupled and dynamited the train, wouldn't that have prevented the disaster?

IIRC, that train only sat there for 8-10 hours. If the train been dynamited, would enough leakage from the cylinders have occurred during that time to let the train get away? I know it was cold, and that hastens leakage.

Didn't the tank cars push or pull the engines down the hill?

Did he leave air on the train because he wanted to avoid having to pump up the train when he went back on duty? So just set a handful af hand brakes? And probably the independent brakes on the units?

I can't remember now if he was convicted of a crime, but I think not. Seems like he should have been, but maybe I'm overlooking something. I know there was a fire on one unit, but I don't see how that would play into this?

During the runaway, were the units continuing to supply air?

[Euclid]

Lithonia Operator

Thanks, guys.

In the Lac Megantic tragedy, did the engineer leave air in the train? Isn't that called "bottling air," and against rules?

With like 80 sets of brakes on those tank cars, if the engines had uncoupled and dynamited the train, wouldn't that have prevented the disaster?

IIRC, that train only sat there for 8-10 hours. If the train been dynamited, would enough leakage from the cylinders have occurred during that time to let the train get away? I know it was cold, and that hastens leakage.

Didn't the tank cars push or pull the engines down the hill?

Did he leave air on the train because he wanted to avoid having to pump up the train when he went back on duty? So just set a handful af hand brakes? And probably the independent brakes on the units?

I can't remember now if he was convicted of a crime, but I think not. Seems like he should have been, but maybe I'm overlooking something. I know there was a fire on one unit, but I don't see how that would play into this?

During the runaway, were the units continuing to supply air?

 

There have been many, many questions and answers about the role of airbrakes in the MM&A runnaway. The number of facets to those questions is very extensive.  It gets into the rules, the push/pull test, and the QRB valve.  It gets into how the air could have bled off the trainline without causing an application.  The fire did not play a direct role, but was nevertheless blamed along with the firemen in various ways.

The net conclusion was that the engineer did not set enough handbrakes, but relied on air to make up for the shortage of handbrakes.  So not setting enough handbrakes was the charge against him, and he was found guility, but only lightly senteneced, as I recall. 

There was no bottled air.  As I recall, the automatic brake was left released, so no dynamiting of the brakes.  The trainline was left charged and brakes released.  But the independent brakes were set to supplement the insufficient number of handbrakes.    

[MMLDelete]

Thanks, Euclid.

I read the report a few years ago, but memory is not my long suit these days.

I wonder if cutting the engines off would have on its own, even with no handbrakes, prevented the runaway. I have no idea how long the average reservoir/cylinder can hold adequate air, much less in bitter cold.

Maybe the loco fire caused the independent brake to fail. Isn't an independent brake "straight air," and braking is achieved by applying, not releasing, air?

[BaltACD]

Lithonia Operator

Thanks, guys.

In the Lac Megantic tragedy, did the engineer leave air in the train? Isn't that called "bottling air," and against rules?

With like 80 sets of brakes on those tank cars, if the engines had uncoupled and dynamited the train, wouldn't that have prevented the disaster?

 

During the runaway, were the units continuing to supply air?

Not sure of Canadian air brake rules.  In the US when at cut of cars is 'off air' for more than 4 hours then a Class 1 brake test is required when the cars are again put on air for movement.  A Class 1 brake test is applying the brakes and observing all brakes are appled, then releasing the brakes and observing all brakes are released.  The observation, in the wild, is normally done by the Conductor walking the entire cut.

At Lac Magentic, the engineer left one unit running, with the Independent Brake applied on the engine consist.  That unit caught fire, the Fire Department in extinguishing the fire used the 'Emergency Fuel Shut Off' to shut the engine down.  Over time the brakes that had been applied to the engines released and in concert with the lack of the required number of hand brakes on the train - the train rolled away. (note - hand brakes on engines only apply on one truck).

 

[Euclid]

Lithonia Operator

I wonder if cutting the engines off would have on its own, even with no handbrakes, prevented the runaway.

I am not sure I understand what you mean.  His securement was a combination of independent brakes and handbrakes, but the number of handbrakes he applied was insufficient to hold the train on its own.  So he supplemented with the independent brakes.  This method was not legal, as there must be no reliance on air brakes for the securement. 

I gather when you refer to cutting off the engine, your point is that it would have dynamited the automatic brake.  I believe there is almost a 100% chance that had the automatic been left in Emergency by an Emergency application, or even by cutting off the engine, the application would have held the train overnight easily.  It might have held the train for much longer, such as two months. It would have depended on the condtion of the brake cylinder packing on each tank car.  But in any case, such reliance on air was prohibited. And the enginner did not leave the brakes applied in Emergency.  He left them fully released with the trainline fully charged. 

[Euclid]

One role played by the fire was that it resulted in no engines running to pump air.  This would not have mattered if there was not reliance on air to secure the train.  And there should not have been such reliance.

However, perhaps the most perplexing question was how the trainline could have  leaked down to zero without causing a full service application.  This was eventually explained as being the result of there needing to be a minimum rate of trainline pressure reduction to cause a corresponding service application to develop.  This is due to an intentional physical feature of the brake valve under each car.  But I don't off hand recall the details.  Suffice it to say the trainline leaked down to zero too slowly to cause any application of air to the brake cylinders. 

In any case, the train ran away with all car brake reservoirs fully charged and ready and able to fully set the brakes, but no controlling feature to bring that about. So the train ran away with all brakes released except for an inadequate number of handbrakes.   

[Overmod]

I think that reviewing the old Megantic threads -- painful as that might be at times! -- will help you re-connect with all the things that went wrong.

The train was left 'hanging on the independent brake' because a full application of the automatic would have required walking the consist after it was set -- by the one man present, after he had set the requisite number of handbrakes -- followed by a similar excursion by the American relief engineer in the morning.  Obviously Harding didn't have two more duty hours at 1:00 in the morning to be walking the consist.  Yes, if the Westinghouse had been applied there would probably have been no accident.

Yes, had "enough" handbrakes been applied, the train would not have run away.  It was obvious to me that even the Ellis-recommended 'number of brakes' would be insufficient to hold a train at the head of a 2% grade, but that doesn't matter now.  What does is that a near-sufficient number of handbrake sets might have kept the peak speed of the train low enough to preclude derailing at just the wrong place.  

The locomotive was delivered from GE with circuitry that activated the Westinghouse brake when independent air fell below a certain level -- I believe that was 14psi set; Randy Stahl will probably know exactly.  This device had been disabled on the locomotive in question.  If it had not been, there likely would have been no accident.

The truly idiot move was something not MM&A developed, but as silly in hindsight as putting a fast-acting block valve on the main steam exit of a BWR.  The type of FRED used on the train used a little parasitic air turbine to keep the power for the rear-end brake valve (which would never be actuated with no one in the cab) and the little red blinking light charged up -- the CFM for this being intentionally below what the pressure-maintaining feature of the Westinghouse brake would supply with the air compressors running.  There does not seem to be any active provision in the devices to suppress this operation should the trainline pressure decrease below ... well, safe pressure for a service set, which would still have held significant pressure on the locomotive independent brake.  

The crowning touch of idiocy was leaving only a known sick locomotive running as the only 'pumping' locomotive in a consist.  It would have taken Harding a few more minutes to set up the consist so that the leader was not the 'running' locomotive; as I recall (to his credit) he did ask those buffoons in the RTC if he should do that and they told him no.  Had even one of the other locomotives been running there would likely have been no accident; had the only running locomotive have been shut down a different way, there would likely have been no accident; had the firemen taken the lever off the seat and confirmed that the train brakes were on, there would likely have been no accident.

As things developed, had it not been over the Fourth of July holiday, there might not have been an accident, as MM&A support forces would have recognized nearly immediately the problem involved in leaving a standing train under their procedures with no running locomotives, and given appropriate instruction.  I don't blame them for this, but I think they blame themselves.

By the time a derailment would have 'dynamited the air' there wasn't sufficient trainline pressure to move the valves to emergency.  I think the runaway started with the train air sagging throught about 14psi (the exact number was reported in the telemetry, I think in one of the TSB reports) and of course ran progressively lower as the independent leaked off more and the train gathered speed.

Had any unit been supplying air, there would likely have been no accident; had any unit been active to recognize falling independent pressure and set the main air, there "might" have been enough left to provide a service set from the (full) car reservoirs.  Were the independent on the locomotives applied from reservoirs rather than as proportional straight air brake, the loss of trainline pressure would not have resulted in proportional release ... shoulda, woulda, coulda.

[MMLDelete]

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train. Meaning if they have to call crew to assist in the brake test, so be it; for crying out loud.

So ... how did that cost-savings work out?

[Euclid]

Lithonia Operator

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train. Meaning if they have to call crew to assist in the brake test, so be it; for crying out loud.

So ... how did that cost-savings work out?

 

The reason the engineer did not leave the automatic brakes applied in Emergency or with a Full Service application, but rather fully released, was that MM&A had a rule requiring them to be left released. 

But neither type of application is considered adequate for train securement where securement is necessary due to being on a grade.  Only handbrakes are acceptable for such securement.  The engineer failed to set enough handbrakes.  That is the sole cause of the runnaway. 

 

[Overmod]

Lithonia Operator

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train.

Actually, no, you'd gain little because you'd still have to set the mandatory number of brakes on the train.  As it happened in this particular vast concatenation of events, setting the air would have been as safe as 'emergency' ... as would simply having a derail set behind the train, a far better and simpler expedient than anything relying on air brakes for unattended retention...

The real 'cost-economizing' issue was in having single-man crews on undegassed oil trains with all but one poorly-functioning engine shut down in the first place.  Once that decision had been made, a very good argument could be made that repeated full application and release of the train brakes with only single manning present at a time would cause far more risk of sticking, dragging, derailment and other issues to those consists than even the pathetic excuse for handbrake application that Canadian law required would create.

... if they have to call crew to assist in the brake test, so be it; for crying out loud.

The logistics of this would involve having an employee 'on retainer' doing nothing but brake tests, probably without their duty hours coinciding at all with arriving full and empty trains ... so assume more than one.  Repeat this at the other locations where crew changes were expected.  Add additional crew for those times your 'regulars' were not available.  All this for savings much more easily achieved in six or seven other areas where -- as it turned out -- there would be trouble if everything went out at the same time.

Randy among others noted that simply restoring the relays on some of the engines involved would have prevented the accident completely.  As would, as I recall, a simple rewire to supply battery power to said relays on units isolated for 'fuel saving' on this type of train.  A very simple GPS-based device in that FRED which detected 'uncommanded' absolute position change, let alone motion, to toggle the air valve there would have likewise prevented this.  With almost none of the cost and risk associated with full sets (or emergency!) every time.

As I recall, the issue of using derails, which was the sane thing regardless of anything to do with train brakes at all, was in fact considered, and as I dimly recall it was illegal under Canadian law (as it would put physical point derails in what was considered a main track, although as I recall there was siding track available at that point) rather than constituting a potential 'loss of running hours' in having the trainman (or some contract employee) go to the rear or front of a standing consist as appropriated to throw the derail appropriately.  (It was never clear to me at the time whether both ends of the consist were accessible from a road down into Megantic.)

So ... how did that cost-savings work out?

It didn't.  But cost-cutting wasn't one of the proximate reasons actually causing that accident, only contributing factors to its occurrence after all the proximate factors were 'in play'.

In retrospect what I asked myself is whether, were I in Ed Ellis' position, would have worked these consists single-manned; the answer was "yes I would" but with nowhere near the number of corners cut as MM&A did.  One of the biggest changes involved something out of Ed's control, the subsequent PHMSA mandatory degassing of Bakken crude for rail transport, and I think that one-main crewing could be made workable at very close to the cost Ed was incurring were that one change to have been made when it should have been -- before any major traffic in crude-oil trains actually ran.

[BaltACD]

Overmod

In retrospect what I asked myself is whether, were I in Ed Ellis' position, would have worked these consists single-manned; the answer was "yes I would" but with nowhere near the number of corners cut as MM&A did.  One of the biggest changes involved something out of Ed's control, the subsequent PHMSA mandatory degassing of Bakken crude for rail transport, and I think that one-main crewing could be made workable at very close to the cost Ed was incurring were that one change to have been made when it should have been -- before any major traffic in crude-oil trains actually ran.

Ed Ellis was not in charge of the MM&A for the Lac Magentic incident, Edward Burkhardt was.

[Overmod]

BaltACD

Ed Ellis was not in charge of the MM&A for the Lac Megantic incident, Edward Burkhardt was.

Thanks; I got my Eds confused.  Fixed in post.

[zugmann]

Lithonia Operator

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train. Meaning if they have to call crew to assist in the brake test, so be it; for crying out loud.

The problem with this:  If you dump the train, and you are on a grade, you still need to apply sufficient handbrakes in order to recharge the train.  If you apply sufficent handbrakes to begin with (and test their effectiveness), then there is no need to dump the train. 

[zugmann]

Euclid

  That is the sole cause of the runnaway. 

I would use "primary" instead of sole.  There were a lot of contriubuting factors. 

[Paul Milenkovic]

The aviation people who discuss their accidents over at Professional Pilots' Rumor Network have an expression "The holes in the Swiss cheese lined up."

The Swiss cheese analogy is that you can have "holes", a shortcut here, a design deficiency there, and ill-thought out rule somewhere else and deficiencies in training to top it all off.  Each of those holes by itself is not enought to cause an accident because as in a Swiss cheese, the holes are not connected.  In rare instances, however, the "holes line up", and all of the above mentioned circumstances break the wrong way to cause an accident.

I mean who anticipated that the locomotive preventing the cars from rolling would catch fire, the fire fighters would press the emergency fuel cutoff, and this action would "take the locomotive offline" from preventing the cars from rolling.

All of the history books about railroading discuss the fail-safe property of the Westinghouse automatic air brake, but upon thinking about it, sometimes the holes in that particular piece of engineered Swiss cheese line up?

[BaltACD]

Paul Milenkovic

The aviation people who discuss their accidents over at Professional Pilots' Rumor Network have an expression "The holes in the Swiss cheese lined up."

The Swiss cheese analogy is that you can have "holes", a shortcut here, a design deficiency there, and ill-thought out rule somewhere else and deficiencies in training to top it all off.  Each of those holes by itself is not enought to cause an accident because as in a Swiss cheese, the holes are not connected.  In rare instances, however, the "holes line up", and all of the above mentioned circumstances break the wrong way to cause an accident.

I mean who anticipated that the locomotive preventing the cars from rolling would catch fire, the fire fighters would press the emergency fuel cutoff, and this action would "take the locomotive offline" from preventing the cars from rolling.

All of the history books about railroading discuss the fail-safe property of the Westinghouse automatic air brake, but upon thinking about it, sometimes the holes in that particular piece of engineered Swiss cheese line up?

Catastrophic incidents - in any form of human activity - are vary rarely because of a single 'failure'.  Most are a result of a relatively long train of events that cascade into the ultimate failure.

[MMLDelete]

zugmann

 

 

Lithonia Operator

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train. Meaning if they have to call crew to assist in the brake test, so be it; for crying out loud.

 

 

The problem with this:  If you dump the train, and you are on a grade, you still need to apply sufficient handbrakes in order to recharge the train.  If you apply sufficent handbrakes to begin with (and test their effectiveness), then there is no need to dump the train. 

 

Thanks for that. Very logical and concise. I had not thought about it that way. You'd need those handbrakes anyway.

Did he set fewer than that railroad's rule required? Or was he by the book, but the RR's rule proved to be inadequate?

[tree68]

Lithonia Operator

Did he set fewer than that railroad's rule required? Or was he by the book, but the RR's rule proved to be inadequate?

As I recall, he included the locomotives in the number of brakes he set.  You're supposed to set X number of cars (depending on the size of the train).  

[MMLDelete]

Meanwhile back at the ranch, does anyone know if RBMN cleaned up their derailment?

[tree68]

Lithonia Operator

Meanwhile back at the ranch, does anyone know if RBMN cleaned up their derailment?

As I recall, someone said they could still get traffic through.  If the cars were essentially stored there, with not immediate use (ie, ballast cars, etc) and the track is not essential for daily ops, they probably aren't in a rush to clean things up.

Or, it's done. 

[Flintlock76]

"The holes in the Swiss cheese line up."

Brilliant!  And it explains so much in so few words.  I'll remember that one.

By the way, has anyone  heard of figured out what caused that Tamaqua derailment?

[tree68]

Flintlock76

"The holes in the Swiss cheese line up."

Brilliant!  And it explains so much in so few words.  I'll remember that one.

By the way, has anyone  heard of figured out what caused that Tamaqua derailment?

Lining up the holes in Hollerith cards wouldn't make sense to most...

Had not the Tamaqua incident occurred next to a road, we probably wouldn't know about it either.

[MMLDelete]

Flintlock76

"The holes in the Swiss cheese line up."

Brilliant!  And it explains so much in so few words.  I'll remember that one.

Really. What a perfect analogy.

[Overmod]

tree68

As I recall, he included the locomotives in the number of brakes he set.

Which was a mistake in several respects.  The brake only applies on one axle, not through the foundation.  

[Overmod]

tree68

As I recall, he included the locomotives in the number of brakes he set.

Which was a mistake in several respects.  The brake only applies on one axle, not through the foundation.  It was applied with the independent already set through the foundation.  As I recall there was a technical problem with at least one of the locomotives that prevented the application from being made effectively (the TSB making more of this than I think it was worth).

I never did see whether the training material from MM&A called for a more stringent definition of applicable brake type or securement than was called for in contemporary Canadian law.

[Paul Milenkovic]

Lithonia Operator

 

 

zugmann

 

 

Lithonia Operator

Man, a giant train of oil cars, left on a 2% grade, uphill from a town on the outside of a curve. IMO, it should have been mandatory (period, full stop) to dynamite the train. Meaning if they have to call crew to assist in the brake test, so be it; for crying out loud.

 

 

The problem with this:  If you dump the train, and you are on a grade, you still need to apply sufficient handbrakes in order to recharge the train.  If you apply sufficent handbrakes to begin with (and test their effectiveness), then there is no need to dump the train. 

 

 

 

 

Thanks for that. Very logical and concise. I had not thought about it that way. You'd need those handbrakes anyway.

Did he set fewer than that railroad's rule required? Or was he by the book, but the RR's rule proved to be inadequate?

 

 

I am not following the logic, here.

If you "dump the train" (release air from the airbrake line to apply the brakes on the train cars from their on-board air reservoirs) and then later on you "recharge the train" (pump air into the brake line to recharge the reservoirs, which has the effect of releasing the brakes), you are doing that with an operating locomotive consist?  And presumably that consist has enough axles to arrest the train rolling back on account by either powering the traction motors to move forward or by applying the locomotive independent brake?

I can understand the need for either brake line retainers or for dynamic braking to control a train on a long downgrade because using the independent brake under those circumstances may burn up the more limited number of brake shoes and wheels absorbing all of that energy of coming down a mountain.  But if you are parked, if the consist has enough traction to restart the train from that location, the independent brake should keep the train stationary until the train car reservoirs are recharged?

I can understand that there is an operating rule to use handbrakes in this situation instead of the power brakes.  Certainly a train parked using the power brake -- the Westinghouse automatic air brake -- could, in theory, leak all of its air from all of the brake reservoirs of the train cars involved, so if a cut of cars is to be kept stationary for days on end, you want to set handbrakes.

But I just don't follow the logic of "if you dump the train . . . on a grade" you need to use handbrakes to release those brakes from a locomotive consist.  Are you telling me everytime a train uses its air brake system to stop on an uphill grade, not a great occurence if you are left without coupler slack to help overcome the starting resistance of a train, but still, a train could receive an adverse signal or receive an order over the radio to stop, that the crew has to get out and set handbrakes as part of the process of getting the train moving again?

[blue streak 1]

As I recall the train was parked on the siding.  A split rail derail with a berm beyond would have been a minor problem to clean up. 

It is correct that most accidents for airlines are a series of failures.  The classic one was the EAL 401 L-1011 accident into the everglades.  The accident report cited 9 items lined up to cause the accident any one different would probably prevented the crash.  It almost did not happen anyway and many persons did survive,

Items were design faults, burned out light bulbs, crew mistakes, air traffic control mistakes, and there was not a real problem other than a faulty  indication.

[zugmann]

Paul Milenkovic

If you "dump the train" (release air from the airbrake line to apply the brakes on the train cars from their on-board air reservoirs) and then later on you "recharge the train" (pump air into the brake line to recharge the reservoirs, which has the effect of releasing the brakes), you are doing that with an operating locomotive consist?  And presumably that consist has enough axles to arrest the train rolling back on account by either powering the traction motors to move forward or by applying the locomotive independent brake?

Depending on what you have and where you are - the engines will NOT be enough to hold the train on a grade.  So yeah, you need handbrakes to recharge if you dump the air.  Note that I'm talking about an emergency application - not a service one.   

 

 

 

[Euclid]

BaltACD

 

Paul Milenkovic

The aviation people who discuss their accidents over at Professional Pilots' Rumor Network have an expression "The holes in the Swiss cheese lined up."

The Swiss cheese analogy is that you can have "holes", a shortcut here, a design deficiency there, and ill-thought out rule somewhere else and deficiencies in training to top it all off.  Each of those holes by itself is not enought to cause an accident because as in a Swiss cheese, the holes are not connected.  In rare instances, however, the "holes line up", and all of the above mentioned circumstances break the wrong way to cause an accident.

I mean who anticipated that the locomotive preventing the cars from rolling would catch fire, the fire fighters would press the emergency fuel cutoff, and this action would "take the locomotive offline" from preventing the cars from rolling.

All of the history books about railroading discuss the fail-safe property of the Westinghouse automatic air brake, but upon thinking about it, sometimes the holes in that particular piece of engineered Swiss cheese line up?

 

 

Catastrophic incidents - in any form of human activity - are vary rarely because of a single 'failure'.  Most are a result of a relatively long train of events that cascade into the ultimate failure.

 

Regarding the notion that big disasters have multiple causes as a string of events leading up to the disaster.  In my opinion, this is based on flawed logic.  The purpose seems to be to diffuse the blame, so there is less blame per person.  That way, with any accident, the person at fault is made less at fault.   Another reason for this multiple blame technique is for a person being blamed to be able to deflect blame by transferring it to another party to the disaster. 

The Lac Megantic runaway would not have happened if the one running locomotive had not been shut down for due to the fire.  There would not have been a fire had there not been a sub-standard repair on the locomotive.  There also would not have been a fire if the engine had not been left running to pump air.  Does that mean that those factors were part of the cause of the runaway?  A lot of people look at it that way.  They will tell you that every major accident has dozens of factors that all contributed to the cause.  So they conclude that there was not a single cause. 

The problem is that when you start counting all the things that had to happen in order for the accident to happen, the list is endless.  An endless list of causes means that nobody is to blame.  That seems to be the point. 

Otherwise, where to you draw the line?  If you never had gotten out of bed on the day of an accident, you would not have had the accident.  The accident would not have occurred had there not been the origin of time and space.

In the case of Lac Megantic, the firemen did nothing wrong in shutting down the engine.  In fact the rules required that action by the firemen.  Believing that accidents have a large number of causes just offers the opportunity to spread the blame around.  That seems to be the point.  If anything defines a cause, it is a factor that was based on negligence, usually toward the end of the chain of events.  In a legal sense, that may be referred to as, “last chance to prevent.”

In this case, the engineer violated the rules on train securement, so that was the point of prosecuting him.  In the simplest of terms, he failed to set enough handbrakes according to the rules.  That was the last action in the chain of events, and it was also against the law.  That alone was the cause.  

In the Lac Megantic disaster, the president of MM&A was being blamed for having a role.  Apparently as a reaction, he blamed the firemen for shutting off the engine during their involvement with fighting the fire.  Shortly after, the President shifted the blame to the engineer of the runaway train. 

[zugmann]

Root causes and contributing factors.  

[MidlandMike]

Euclid

In the case of Lac Megantic, the firemen did nothing wrong in shutting down the engine.  In fact the rules required that action by the firemen.  Believing that accidents have a large number of causes just offers the opportunity to spread the blame around.  That seems to be the point.  If anything defines a cause, it is a factor that was based on negligence, usually toward the end of the chain of events.  In a legal sense, that may be referred to as, “last chance to prevent.” In this case, the engineer violated the rules on train securement, so that was the point of prosecuting him.  In the simplest of terms, he failed to set enough handbrakes according to the rules.  That was the last action in the chain of events, and it was also against the law.  That alone was the cause.  

Anyone who was negligent in the series of events was a contributing factor.  The engine(s) were poorly maintained, procedures were flawed, manpower was spread too thin, the engineer was fatigued, and others were also prosecuted.  Humans make mistakes, and there needs to be multiple layers of safety to prevent disasters.  The MM&A was an accident looking for an inevitable opportunity.

[Euclid]

MidlandMike

 

Euclid

In the case of Lac Megantic, the firemen did nothing wrong in shutting down the engine.  In fact the rules required that action by the firemen.  Believing that accidents have a large number of causes just offers the opportunity to spread the blame around.  That seems to be the point.  If anything defines a cause, it is a factor that was based on negligence, usually toward the end of the chain of events.  In a legal sense, that may be referred to as, “last chance to prevent.” In this case, the engineer violated the rules on train securement, so that was the point of prosecuting him.  In the simplest of terms, he failed to set enough handbrakes according to the rules.  That was the last action in the chain of events, and it was also against the law.  That alone was the cause.  

 

 

Anyone who was negligent in the series of events was a contributing factor.  The engine(s) were poorly maintained, procedures were flawed, manpower was spread too thin, the engineer was fatigued, and others were also prosecuted.  Humans make mistakes, and there needs to be multiple layers of safety to prevent disasters.  The MM&A was an accident looking for an inevitable opportunity.

 

How many contributing causes were there with the Lac Megantic disaster? 

[tree68]

Euclid

How many contributing causes were there with the Lac Megantic disaster? 

MM just listed a number of them.  

Some are hard to quantify with the information we have.  F'rinstance, was locomotive maintenance substandard because of a management philosophy?  Was the mechanical department unable to do the proper work?  Were the locomotives themselves beyond economical repair? 

The possibilities are endless.   I'm sure the trial transcript has a more complete list.

As has been noted, removal of even one factor would probably have prevented the incident.  Who knows - all it might have taken was the handbrake on one more car.  (That's rhetorical - no need to dissect it.)

[zugmann]

Euclid

How many contributing causes were there with the Lac Megantic disaster? 

TSB lists 18.

https://www.tsb.gc.ca/eng/rapports-reports/rail/2013/r13d0054/r13d0054-r-es.html

[Murphy Siding]

tree68

 .... Who knows - all it might have taken was the handbrake on one more car.  (That's rhetorical - no need to dissect it.) 

 

[Euclid]

I agree that if you define causes the way TSB does, there will be a lot of them.  They are countless.  If not one cause, where do you draw the line?  That is my point. 

The TSB conclusions make my point.   I contend that the Lac Megantic disaster had one cause, and not eighteen causes. 

That one cause is identified in TSB’s wheel of causes and contributing factors as follows:  Insufficient hand brakes

 

So they say they found 18 distinct causes and contributing factors, but they make no distinction between a cause and a contributing factor.  Clearly they have linked causes and contributing factors into one entity.  So each of their 18 items is a cause and a contributing factor.  It is not different than referring to each of the 18 as a contribution to the cause.  So they are saying that the contributing factors are each a contributing cause, and thus each is a portion of the cause.  In other words, they are saying there were 18 causes. They reinforce this conclusion by saying:

“Investigations conducted by the TSB are complex—an accident is never caused by just one factor.”  

“The tragedy in Lac-Megantic was not caused by one single person, action or organization.” 

[MMLDelete]

zugmann

 

 

Paul Milenkovic

If you "dump the train" (release air from the airbrake line to apply the brakes on the train cars from their on-board air reservoirs) and then later on you "recharge the train" (pump air into the brake line to recharge the reservoirs, which has the effect of releasing the brakes), you are doing that with an operating locomotive consist?  And presumably that consist has enough axles to arrest the train rolling back on account by either powering the traction motors to move forward or by applying the locomotive independent brake?

 

 

Depending on what you have and where you are - the engines will NOT be enough to hold the train on a grade.  So yeah, you need handbrakes to recharge if you dump the air.  Note that I'm talking about an emergency application - not a service one. 

 

 

 

Zug, this confuses me. I have two basic questions.

1) Why the difference between there having been an emergency application, and there having been a service application?

It seems to me that in either case, to get going again you will need to release the brakes. And to do that you'd have to set some handbrakes.

Am I not correct that train brakes can be set in degrees of application, but a release has to be a complete, 100% release?

2) Now, what is the procedure for starting a stopped train on a grade?

Is it like this: With the independent and the handbrakes applied, you completely recharge the system. This releases the train brakes. Then you make a service application which experience tells you will just barely hold the train, but OTOH, is not so great a degree of application that it prevents the loco consist, when full power is applied, from pulling the train up the grade even with the train brakes applied. You now release the handbrakes. Then you shove it to Run 8, release the independent, and get the train moving, with the train brakes still applied. Once you determine you have enough momentum to keep proceeding up the hill, you release the train brakes. ???

I hope it's really simpler than that, but I can't figure how it could be done otherwise.

[BaltACD]

Lithonia Operator

 

zugmann 

Paul Milenkovic

If you "dump the train" (release air from the airbrake line to apply the brakes on the train cars from their on-board air reservoirs) and then later on you "recharge the train" (pump air into the brake line to recharge the reservoirs, which has the effect of releasing the brakes), you are doing that with an operating locomotive consist?  And presumably that consist has enough axles to arrest the train rolling back on account by either powering the traction motors to move forward or by applying the locomotive independent brake? 

Depending on what you have and where you are - the engines will NOT be enough to hold the train on a grade.  So yeah, you need handbrakes to recharge if you dump the air.  Note that I'm talking about an emergency application - not a service one.  

Zug, this confuses me. I have two basic questions.

1) Why the difference between there having been an emergency application, and there having been a service application?

It seems to me that in either case, to get going again you will need to release the brakes. And to do that you'd have to set some handbrakes.

Am I not correct that train brakes can be set in degrees of application, but a release has to be a complete, 100% release?

2) Now, what is the procedure for starting a stopped train on a grade?

Is it like this: With the independent and the handbrakes applied, you completely recharge the system. This releases the train brakes. Then you make a service application which experience tells you will just barely hold the train, but OTOH, is not so great a degree of application that it prevents the loco consist, when full power is applied, from pulling the train up the grade even with the train brakes applied. You now release the handbrakes. Then you shove it to Run 8, release the independent, and get the train moving, with the train brakes still applied. Once you determine you have enough momentum to keep proceeding up the hill, you release the train brakes. ???

I hope it's really simpler than that, but I can't figure how it could be done otherwise.

CSX Mountain Sub TTSI

2. All Trains – If speed cannot be maintained at or below the authorized speed for the train descending the grades listed above:

A. The train must be stopped immediately by making an emergency brake application of the air brakes including the operation of the two-way EOT emergency toggle switch.

B. The train dispatcher must be contacted.

C. After stopping a minimum of 50% of train hand brakes must be applied before the recharging procedure is initiated.

D. The brake pipe must be recharged for a minimum of 20 minutes. The rear car air pressure must be within 5 PSI of the pressure shown on the HTD when the head end of the train began the descent.

E. After recharging the air brake system to the required rear car air pressure, a 6 to 8 pounds brake pipe reduction must be made. After the brake pipe exhaust ceases, each car will be visually inspected to determine the brakes are applied, piston travel is within standards and brake shoes are against each wheel.

F. The train may proceed only after being authorized by the Road Foreman of Engines or the Trainmaster. If needed, hand brakes may be left on the train to supplement train air brakes descending the remainder of the grade. To prevent sliding of wheels, avoid leaving hand brakes on any empty cars.

Note: Should the train separate, hand brakes must be applied to each portion of the train to hold each section on the grade.

G. Stopped on Grades – When recharging the train air brake system on descending grades of 1% or more, recharge the brake system for a minimum of 20 minutes.

Note: During temperatures less than 32 degrees or inclement weather, additional charging time may be required. Trains must not proceed until the brake pipe is properly charged.

Recharging and releasing brakes when trains are on grades require thought and skill.

[zugmann]

Euclid

I agree that if you define causes the way TSB does, there will be a lot of them.  They are countless.  If not one cause, where do you draw the line?  That is my point. 

18 is countless?

Euclid

The TSB conclusions make my point.   I contend that the Lac Megantic disaster had one cause, and not eighteen causes. 

That's fine and dandy, but I'll put my faith in the TSB over Mr. Euclid from the train forums. 

[zugmann]

Lithonia Operator

Then you shove it to Run 8, release the independent, and get the train moving, with the train brakes still applied. Once you determine you have enough momentum to keep proceeding up the hill, you release the train brakes. ???

No. Most likely you're not going to move the train with the train brakes applied.  All that will do is start to spin the wheels. at which point the engine will dump its load and stop providing traction. 

[MidlandMike]

Euclid

I contend that the Lac Megantic disaster had one cause, and not eighteen causes.  That one cause is identified in TSB’s wheel of causes and contributing factors as follows:  Insufficient hand brakes

If you want to prevent the disaster from happening again, then you look for and fix all the causes.  If you just want to punish someone and ignore other inconvenient problems, then you look for a fall guy and pretend the problem is solved.

[Paul Milenkovic]

jeffhergert

 

 

Lithonia Operator

 

 

BaltACD

Sounds like someone got tired of seeing them where they were parked and released the handbrake(s).

 

 

 

 

Would that cut have likely been left there with air in the train line?

If there was NO air in the train line, the brakes would be applied, right? Because the reservoirs' air would apply them, right?

The reason I ask is because you said someone must have released the handbrakes. But I'd think they still wouldn't roll, because of the reservoirs.

Are handbrakes used because the pressure in the reservoirs will inevitably leak out over time?

When I see a cut of cars sitting somewhere, is there air in the brake pipe? Or has all the air, both in the brake pipe and the reservoirs, been released?

When the train that had those cars set them out there, what was the routine regarding brakes? (assuming it was done by the book)

Help me out here, guys.

Am I hopelessly confused about railroad brakes?

 

 

 

 

When cutting away they should, and probably did, allow the brake pipe to "dynamite" putting the air brakes at their highest braking force.  However, the brake cylinders can leak off over time.  Some may hold for weeks, maybe months.  Others may only hold for minutes or hours.  That's why hand brakes are applied.

If someone had malicious intent and knew enough to release the hand brake, there's a good chance they would know about bleeding off the brake cylinders.  

Jeff

 

 

So the automatic air brakes can leak off in a matter of minutes?

How does anyone descend a grade of any length using air brakes if this is the case?

I "get" that train handling is an art, but the notion that if a train has to stop on a grade that it is so underpowered that hand brakes have to be set as part of the process of restarting the train -- what century are we living in?

I am a research engineer, and the idea that there is no redundancy, backup system or "engineering margin" in railroad operations of trainloads of highly flammable cargo is astounding (crude oil is just that, it has a lot of what becomes gasoline mixed in with what becomes motor oil). 

So you dispatch and operate this 8000 ton oil train with a GE locomotive belching multiple colors of smoke, but it is not the fault of Power Dispatch, it is the fault of the locomotive engineer for not setting enough handbrakes?  So you are going to dispatch a transatlantic jet with one of its engines belching smoke because a competent pilot is going to know how to fly the jet on one engine?

There is something broken with the safety culture in railroading if the failure of every possible backup is excused -- conducting a crew change on a steep grade, conducting a crew change on a steep grade leaving the train unattended, a locomotive without a fail safe that if it shuts down it doesn't release the independent brake, tank cars of a hazmat cargo that don't actuate the automatic air brake from a slow bleed-off -- none of this matters because this is just how railroading is done? 

And it is all the fault of a single-crew locomotive engineer for a lapse in his doing a brake test on hand brakes?  And never mind that 47 people perished and many more had their homes burnt, we will criminally prosecute this one guy, to set an example for the others as a deterrent to another single-crew locomotive engineer at the end of his allowed hours taking a short cut on securing a train.

What the locomotive engineer did was in violation of the rules, and taking every fail-safe and backup to protect against such a rule violation is "how we do things in railroading"?

[MMLDelete]

zugmann

 

 

Lithonia Operator

Then you shove it to Run 8, release the independent, and get the train moving, with the train brakes still applied. Once you determine you have enough momentum to keep proceeding up the hill, you release the train brakes. ???

 

 

No. Most likely you're not going to move the train with the train brakes applied.  All that will do is start to spin the wheels. at which point the engine will dump its load and stop providing traction. 

 

So you leave the handbrakes applied, and try to drag the train up the hill that way? Then once you find a level spot, stop and release the handbrakes?

Or (if you've stalled going up a hill), do you set enough handbrakes on the rear half of the train to hold it, make a cut, and double the hill, IF there is a siding at the top of the hill so you can run around the front half?

Or do you call the dispatcher for help, then sit there and await the arrival of pushers?

[MMLDelete]

Paul Milenkovic

I "get" that train handling is an art, but the notion that if a train has to stop on a grade that it is so underpowered that hand brakes have to be set as part of the process of restarting the train -- what century are we living in?

Paul, my guess is that most trains can re-start if they've stopped on the grades they usually encounter on that route, by just putting the power to 'er and releasing the brakes.

I think it's a different ballgame, though, if the train has stalled on the grade (as opposed to stopping at a signal, or a crew change, what have you). And my guess, since power is assigned based on tonnage and the ruling grade, is that stalling happens infrequently, and mostly when a unit or two fails. Or, less often, in unusually icy weather.

But hopefully one of our engineers will weigh in again. Me, I only stayed at the Holiday Inn Express.

[Overmod]

Paul Milenkovic

I "get" that train handling is an art, but the notion that if a train has to stop on a grade that it is so underpowered that hand brakes have to be set as part of the process of restarting the train -- what century are we living in?

Mid-to-late Twentieth -- it's a feature, not a bug.

Remember the magic of one-pipe braking, now enhanced with the miracle of pressure maintaining.  This absolutely, positively eliminates any possibility of graduated release of the brakes ... which is what you would need to restart your train on the grade from an applied set.  

The brakes only recharge after a full release, by design -- they have to be all the way off before the reservoirs begin to be filled again.  That is where the problem restarting the train comes in.  As soon as you decide to start and begin loading the locomotives, your only option is to release the brakes ... which is irrevocable; you can't change your mind and reapply them if you find yourself starting to slip backward because your GEs take 30 seconds or whatever to start actually making power.  It won't be easy to get the locomotives to load in dynamic, so you might well get considerable momentum on the train before any help from that quarter develops, and you have to sit there while the 'release and recharge' completes, which is a long time for gravity to be yanking on something with inherently slight rolling resistance.

The handbrakes hold the train while the air brakes are recharging, after which time you have safety if for any reason you have trouble starting the train uphill.  Then you apply the independent (to hold the consist in tension against the train) and can start releasing handbrakes until ... well, until you get to the point Harding had his oil train when he stopped it at Nantes and got off to start applying the handbrakes. 

I'll let a real engineer describe how retainers figure into this, and what the finer points of the operation going downhill, where the locomotives will be throttled up in dynamic, will be.

[Euclid]

zugmann

 

Euclid

I agree that if you define causes the way TSB does, there will be a lot of them.  They are countless.  If not one cause, where do you draw the line?  That is my point. 

 

 

18 is countless?

 

Euclid

The TSB conclusions make my point.   I contend that the Lac Megantic disaster had one cause, and not eighteen causes. 

 

 

That's fine and dandy, but I'll put my faith in the TSB over Mr. Euclid from the train forums. 

 

My point is that if you go looking for causes as defined by TSB, that were not direct such as the frailty of tank cars, you can just as well include the cause of carrying oil.  Everything that has a possible tie in can be included if you define the cause that way.  So where do you draw the line?  18 is not countless, but the terms of the 18 could be used to find as many as you want to list.

Consider the cause, "train left unattended on hill" and the cause, "insufficient hand brakes."  If the latter had never happened, the  runaway would not have happened.  If the runaway had never happened, the train being left unattended on the grade would not have contributed to a runaway.  Therefore, the train being left unattended on the grade cannot be a partial or complete cause to a disaster that never happened. 

 

[Overmod]

Euclid

My point is that if you go looking for causes as defined by TSB, that were not direct such as the frailty of tank cars, you can just as well include the cause of carrying oil.

Well, had the oil been degassed as PHMSA subsequently required, the accident might have just been cars and slimy black stuff all over, and not 47 people and a town lost in flames.  So yes, the oil was a "cause", and a significant one, and getting rid of its danger was one of the most significant responses to the Lac Megantic accident that was made.

But that's not the only place a distinction needs to be made.  Much of the failure in 'safety culture' and 'training' was, to me, not as significant as the TSB wanted to make it be.  Harding was a qualified engineer; he knew (or should have known) what was safe and what was not.  When you have a concatenation of causes, each agent is responsible for those causes he provided or enabled.  In this case, Harding was to 'blame' for not setting proper brakes, and for trusting those two dunces at RFC Farnham when they told him not to go back to his train.  The firemen were to 'blame' for shutting down the engine, the most proximate cause of the disaster.  In a sense the trackwalker they put on the spot was to 'blame' for not communicating that he didn't know the situation -- or the correct actions to take in tying down a train after an engine fire.  In a very real sense, TC regulations were to 'blame' in several respects, most notably with gross errors in what constituted necessary handbrakes and in forbidding use of a positive derail behind the consist. 

But there are also causes we can't 'blame' -- the locomotive maintenance people 'on vacation' and temporarily unreachable either with advice on engine shutdown or fire response, for example.  Merely leaving the train unattended was not enough of a cause to attribute any real 'blame' to, as absence of any of most of the remaining causes would have resulted in a set, and no runaway (although I suspect there would be some cursing when the relief engineer arrived to find he needed to do a two-hour recovery).  That's not to say that leaving any train unattended on a 2% grade, miles above a sharp curve into a populated area, makes any real sense in the first place... any more than shipping nondegassed crude in any economically feasible tank car did.  

[Paul Milenkovic]

Overmod

 

 

Euclid

My point is that if you go looking for causes as defined by TSB, that were not direct such as the frailty of tank cars, you can just as well include the cause of carrying oil.

 

 

Well, had the oil been degassed as PHMSA subsequently required, the accident might have just been cars and slimy black stuff all over, and not 47 people and a town lost in flames.  So yes, the oil was a "cause", and a significant one, and getting rid of its danger was one of the most significant responses to the Lac Megantic accident that was made.

 

But that's not the only place a distinction needs to be made.  Much of the failure in 'safety culture' and 'training' was, to me, not as significant as the TSB wanted to make it be.  Harding was a qualified engineer; he knew (or should have known) what was safe and what was not.  When you have a concatenation of causes, each agent is responsible for those causes he provided or enabled.  In this case, Harding was to 'blame' for not setting proper brakes, and for trusting those two dunces at RFC Farnham when they told him not to go back to his train.  The firemen were to 'blame' for shutting down the engine, the most proximate cause of the disaster.  In a sense the trackwalker they put on the spot was to 'blame' for not communicating that he didn't know the situation -- or the correct actions to take in tying down a train after an engine fire.  In a very real sense, TC regulations were to 'blame' in several respects, most notably with gross errors in what constituted necessary handbrakes and in forbidding use of a positive derail behind the consist. 

But there are also causes we can't 'blame' -- the locomotive maintenance people 'on vacation' and temporarily unreachable either with advice on engine shutdown or fire response, for example.  Merely leaving the train unattended was not enough of a cause to attribute any real 'blame' to, as absence of any of most of the remaining causes would have resulted in a set, and no runaway (although I suspect there would be some cursing when the relief engineer arrived to find he needed to do a two-hour recovery).  That's not to say that leaving any train unattended on a 2% grade, miles above a sharp curve into a populated area, makes any real sense in the first place... any more than shipping nondegassed crude in any economically feasible tank car did.  

 

The setting of blame is not the point.

The point, from considering rail transport of crude oil as an engineering system, is what is a reasonable and prudent number of safeguards to put in place.  Relying on a locomotive engineer to have not make a lapse such as leaving the locomotive independent brake on when testing whether enough hand brakes are set is certainly not enough going forward.  You can threaten capital punishment against a locomotive engineer in the manner that Great Britain acted against one of its admirals, satirized by a French author as an action taken "pour encourager les autres" (to incentivize the other admirals).  But you can still end up with a horrific accident.

Reasonable and prudent are the key words.  Safety measures have to balance risk against cost, because cost, the consumption of economic resources, has a risk all its own into all of the hidden hazards generating a unit of economic outputs.

A list of measures to be considered is, yes, "degassing" the crude prior to shipment to make it less flamable, requiring oil tank cars in unit-train service to set brakes from a gradual loss of brakeline pressure (I am sure someone has a reason for that feature, but not setting the brakes kind of defeats the purpose of the automatic air brake), requiring locomotives to not release the independent brake if they are shut down or shut down on their own, requiring an oil unit train or any other train with hazmat cargo to be attended over the interval of a crew change.

Could there be some rule against dispatching a hazmat unit train with a failing locomotive units -- don't the airlines have a rule about not dispatching a plane with an engine pouring out smoke?  Maybe there should be a rule that on a hazmat unit train, two locomotive units are kept running?

I would not make a rule that the fire department cannot press the fuel cutoff button to put out a fire on an aging General Electric locomotive.  Again, the burden should be on the locomotive design to not release brakes under those circumstances.  Why would you want a locomotive to start rolling if it quit?

Again, people are arguing "You should not use the independent train to secure a train on a hill."  So that is a reason to have the feature of releasing the independent if the locomotive unit is shut down?  You need redundancy, fail-safes and backstops to relying on the locomotive engineer not having a lapse in procedure at the end of a shift.

[zugmann]

Paul Milenkovic

Again, people are arguing "You should not use the independent train to secure a train on a hill."  So that is a reason to have the feature of releasing the independent if the locomotive unit is shut down?  You need redundancy, fail-safes and backstops to relying on the locomotive engineer not having a lapse in procedure at the end of a shift.

If an engine shuts down, the main reservoir and thus independent bleeds off pretty fast (air tanks aren't that big).  Hence parking (hand) brakes. 

 

[Overmod]

Paul Milenkovic

The setting of blame is not the point.

It appears to be so, for him.  Perhaps he perceives it as a matter for 'justice' rather than what it is: lessons written in blood, as so much on the railroad is.  

From a wholly legal standpoint, this may have value in assessing things like deep-pockets liability for massive claims ... or shifting the blame as much as possible across national borders where that is perceived desirable.  What I think it tends to blind people to is the important concern: how do you learn correctly from the accident? and what do you do, and not do, in future?

The point, from considering rail transport of crude oil as an engineering system, is what is a reasonable and prudent number of safeguards to put in place.

More important is to put reasonable safeguards in place that ensure a 'safe course' regardless of complex interactions -- this is behind both 'graceful degrade' and 'failing safe'.  There are at least several examples in the Lac Megantic accident that I will take up later.

 Relying on a locomotive engineer to have not make a lapse such as leaving the locomotive independent brake on when testing whether enough hand brakes are set is certainly not enough going forward.

I'd agree -- and not just because of BaltACD's point about the 'human element'.  Safety systems are not the same thing as 'the safe course' -- many of them, including several that 'shoulda' been present in this case, are precisely for the times when something in that course goes wrong.

You can threaten capital punishment against a locomotive engineer in the manner that Great Britain acted against one of its admirals, satirized by a French author as an action taken "pour encourager les autres" (to incentivize the other admirals).

Or, as here, to find some sort of public scapegoat to play to public horror.  Marching poor Harding around in handcuffs serves no more purpose than reopening criminal charges against Bostian for the Amtrak 188 accident.  (In my opinion, especially when it's part of an ultimate whitewash or grandstanding 'play', but that's a different topic for a different thread...)

Reasonable and prudent are the key words.  Safety measures have to balance risk against cost, because cost, the consumption of economic resources, has a risk all its own into all of the hidden hazards generating a unit of economic outputs.

But let's look for a moment at the specific operating economics of the MM&A oil trains.  Significant compromise to the operating model would have occurred had a full automatic set been taken, and again release of the automatic the following morning.  As things developed, the necessary handbrake set on tank cars ... whether or not the automatic was set ... would have had much the same significant effect.  So the 'reasonable and prudent' now extends to whether a method of securing the train, off grade crossings and sufficiently close to the international border, could have been arranged.

A list of measures to be considered is, yes, "degassing" the crude prior to shipment to make it less flammable,

A given.  Of course it's happened; I've pointed out that the incidence of flaming oil-train derailments has not recurred since.

[quote ...requiring oil tank cars in unit-train service to set brakes from a gradual loss of brakeline pressure (I am sure someone has a reason for that feature, but not setting the brakes kind of defeats the purpose of the automatic air brake)[/quote]It's more complicated than that.  On oil trains in particular an inadvertent dynamiting of the Westinghouse brake might be fully as dangerous as quiet brake failure ... and far more frequently encountered in any operating practice.  (See the discussion in one of the accident threads regarding why the emergency feature built into GE locomotives that actuates the automatic should the locomotive MR pressure drop too low was disabled).

I think there is probably a way, for example, to adapt a FRED with GPS to recognize 'unattended' movement, e.g. with a 'geofence' routine started any time the train is parked, and modulate a commanded set increasing with distance or speed.  Keeping away from 'emergency' until there is actually a need for Full Braking Effort -- emergency brake not meaning the appropriate choice in any emergency, regardless of its name -- is probably a reasonable and prudent design choice in most things involving operation of train brakes in an imperfect world.

... requiring locomotives to not release the independent brake if they are shut down or shut down on their own; ...

That's a tad silly, if you think about it.  What's a reasonable and prudent requirement that keeps planes from losing altitude if their engines are shut down or shut down on their own?  At Lac Megantic the locomotive never 'released' the independent; it stopped working as a straight brake as the line pressure sagged below ~14psi. 

Perhaps there is a way of safely 'bottling' an independent set should the line pressure decrease below a certain level.  I can think of reasons that would not be prudent in other circumstances.  In any case, the default ... which is to progressively engage a set on the automatic brake if the independent is fully engaged and the line or MR pressure drops below a certain level ... is sufficient without additional messing with bailoff vs. retention of the straight locomotive brake.

... requiring an oil unit train or any other train with hazmat cargo to be attended over the interval of a crew change.

I, personally, would think this desirable, just on the grounds of potential vandalism.  It would be nice to have "precision scheduled crew change" where the train is never left 'unattended' because it physically stops as short a time as possible, but that was evidently not part of Ed's operating model.   Logistics of finding an appropriate person in the Lac Megantic area to be 'on call', to go out in the cab that picked up the Canadian engineer and return in the one bringing the American engineer the next morning, might in 20/20 hindsight look workable, but I would question its cost-benefit in the presence of 'better' safeguards.

Could there be some rule against dispatching a hazmat unit train with a failing locomotive units -- don't the airlines have a rule about not dispatching a plane with an engine pouring out smoke?

As I recall, the engine showed relatively little if any signs of incipient failure when dispatched -- the oil leak not becoming serious until Harding flogged it a bit only a few hours before the stop at Nantes (it's in the TSB report somewhere).  Certainly it would 'make sense' to mandate that an engine with significant danger of fire shouldn't be assigned to a trainload of Bakken crude ... but wouldn't that rule out assigning GEs to any such train at all? 

Maybe there should be a rule that on a hazmat unit train, two locomotive units are kept running?

That would make sense to me, but greater still is the sense that it shouldn't 'matter' to reasonable and prudent safety if units are running or not.  The point of handbrake securement is that the train won't move no matter what.  If you were to have an instance where common contaminated fuel was put in multiple units -- perhaps a likely thing on MM&A -- all the units might reasonably shut down within a few minutes of each other.

I would not make a rule that the fire department cannot press the fuel cutoff button to put out a fire on an aging General Electric locomotive.

No, but remember that correctly shutting the unit down would have set the brakes.  Likewise, not diligently inquiring the correct method of checking train securement after meddling with the motive power becomes the fire department's responsibility.  This is a relatively simple thing to arrange ... in hindsight: provide every regional FD with collateral on how to recognize and shut down locomotives in emergencies.  One wonders how many railroads learned this lesson after Megantic...

Again, the burden should be on the locomotive design to not release brakes under those circumstances.  Why would you want a locomotive to start rolling if it quit?

No one did, least of all GE which engineered specific protection against low air pressure into the design of the C30-7.  If there is 'burden' it is in not removing key protection ... this couldn't be reasonably predicted, but it sure is retrospectively valuable.

Again, people are arguing "You should not use the independent [brake] to secure a train on a hill."  So that is a reason to have the feature of releasing the independent if the locomotive unit is shut down?

I think you are confusing the ECP accident with the idiot 'battery saving' unanticipated release with the accident at Lac Megantic.  There was certainly no 'feature' that released the independent in the latter accident, unless you count weird FRED turbogenerator implementation that depends on pressure maintaining running as such.

You need redundancy, fail-safes and backstops to relying on the locomotive engineer not having a lapse in procedure at the end of a shift.

Yeah, and the first of these is a proper checklist; and the second is alarms to prevent overlooking anything not set correctly; and the third is in not employing expedient morons in your RFCs who tell people to shortcut essential procedures ... but I digress.  What we're discussing is failsafes, and those run entirely outside dependence on human attention or 'right action'.

One sensible approach is to equip units in 'hazmat service' with remote start, of the kind used to maintain running temperature where something like a Hotstart isn't used.  This might very easily be modified into an emergency start for consists with a known-bad (or subsequently disabled) unit left as the 'one' running -- with its associated air compressor coming on to keep MR pressure, and hence any independent set, good.  If you need to keep the consist warm, you might even 'round-robin' the running unit to maximize the fuel savings...

It occurs to me that a relay that sets the Westinghouse brake in the event of low MR pressure inherently does just what Prof. Milenkovic argues against: partially releasing the pressure on the independent (as it relieves the brake-pipe pressure to make the set).  Again I see more risk in providing ways 'around' this than in tolerating it.

The more essential issue involves that of routing the train in such a way to permit safe derail upon uncommanded movement, well shy of enough momentum to generate disaster.  I believe at Nantes there was, in fact, a siding that could have been provided with 'points' derail at an appropriate location, not involving an 'illegal' derail placed in a main.  (Again, I think this was brought up in the TSB report).  

[Euclid]

Paul Milenkovic

I would not make a rule that the fire department cannot press the fuel cutoff button to put out a fire on an aging General Electric locomotive.  Again, the burden should be on the locomotive design to not release brakes under those circumstances.  Why would you want a locomotive to start rolling if it quit?

 

There was no such rule.  As I recall, there was a rule telling the firemen to use the emergency fuel cutoff as the first move, and that it what they did. It immediately shut off the engine and stopped the fire, which was mostly in the exhaust manifold.  A worker from MM&A was there on scene with the firemen to act as their representative for the railroad. 

All of the information about the fire, including the effort to extinguish it, and the fact that the one locomotive that had initially been left running and was on fire; and had been left shut down after the fire was put out—  all of that information was conveyed to the two MM&A supervisors before the firemen and the company rep left the scene.    

The burden, as you say, is not on the locomotive design, but rather, it is on the car hand brakes.  Setting adequate hand brakes is the only allowable means of securing a train.  Any securement reliance on air brakes, either independent or automatic, is strictly forbidden by rules and laws.  If that requirement had been followed, there would have been no problem in shutting down the engine and losing air pressure.

The issue of technological deficiency is the manual hand brake on railcars.  Its concept dates back to the 1800s.  Securing a big train on a steep grade can require setting 50-75 hand brakes by people walking the train.  Ideally, there would be one button you could push that would set all those hand brakes automatically with a controlled power source. 

[Overmod]

Euclid

A worker from MM&A was there on scene with the firemen to act as their representative for the railroad.

An elderly worker with no knowledge of locomotives, or who to reach to obtain it.  We have discussed this at some length.    

All of the information about the fire, including the effort to extinguish it, and the fact that the one locomotive that had initially been left running and was on fire; and had been left shut down after the fire was put out, and the firemen and company rep left the scene—all of that information was conveyed to the two MM&A supervisors before the firemen and the company rep left the scene.

The same defective duo who kept Harding from coming back up to take care of his train when he found out there was trouble.  

Randy did point out that some attempts to reach the 'right' people at MM&A were tried, and had it not been Fourth of July vacation, someone would have figured things out 'timely' and gotten the situation handled.  There are so many ways that 'handling' could have been done and the accident itself prevented.

[Euclid]

Overmod

 

Euclid

A worker from MM&A was there on scene with the firemen to act as their representative for the railroad.

 

 

An elderly worker with no knowledge of locomotives, or who to reach to obtain it.  We have discussed this at some length.    

 

 

All of the information about the fire, including the effort to extinguish it, and the fact that the one locomotive that had initially been left running and was on fire; and had been left shut down after the fire was put out, and the firemen and company rep left the scene—all of that information was conveyed to the two MM&A supervisors before the firemen and the company rep left the scene.

 

 

The same defective duo who kept Harding from coming back up to take care of his train when he found out there was trouble.  

 

Randy did point out that some attempts to reach the 'right' people at MM&A were tried, and had it not been Fourth of July vacation, someone would have figured things out 'timely' and gotten the situation handled.  There are so many ways that 'handling' could have been done and the accident itself prevented.

 

So that means the firemen are responsible for the disaster?  I am only responding to the continuing tendancy to blame the firemen for shutting down the engine.  What were they supposed to do? 

Was it their responsibility to track down the highest authority of MM&A to let them know?  They did officially notify the corporation through the MM&A employees who were directly involved.  If those employees were not competent enough to act responsibly, that is not the fault of the fire department.

[Overmod]

Euclid

So that means the firemen are responsible for the disaster?

The firemen SHARE responsibility for the disaster.  Had they not shut the locomotive down improperly and incompletely, in fact had they continued into the locomotive and shut down the battery connection (as firemen usually do with automobile fires) I believe the brakes would have been applied.

No one is "blaming" them for "causing" the accident.  But without them doing what they did and didn't do, it would almost certainly not have occurred.  To see that distinction, I think you may need to ponder the koan more carefully.

What were [the firemen] supposed to do?  Was it their responsibility to track down the highest authority of MM&A to let them know?  They did officially notify the corporation through the MM&A employees who were directly involved.  If those employees were not competent enough to act responsibly, that is not the fault of the fire department.

If I remember correctly, one of the reasons for 'haste' in hitting the unit emergency switch was paranoia about an EXPLODING OIL TRAIN that had visibly caught fire.  Evidently they thought that the danger was over when the flames were out.

"Should they have known" that the train brakes were hanging on a running locomotive?  They couldn't know.  I find it hard to believe those folks at Farnham didn't know standard procedures, though, and those people clearly understood there were no running engines on a train largely secured by its independent brake.  

In my opinion, the 'blame' lies with not connecting dots, and can't be laid to any 'one' person or group.  On the other hand, of all the groups that night most conscious of the awful hazard that train represented, firemen would be at the top of the list, and confirming that train's security ... not just passing the buck in the middle of an American-holiday night ... perhaps ought to have been more of a priority than it proved to be.

[tree68]

Euclid

So that means the firemen are responsible for the disaster?

They were but one of the holes in the Swiss cheese that lined up for that incident.

[BaltACD]

tree68

 

Euclid

So that means the firemen are responsible for the disaster? 

They were but one of the holes in the Swiss cheese that lined up for that incident.

There was only ONE man who could have stopped the Swiss Cheese Holes from ever getthing the opportunity to line up.  The Engineer that DID NOT PROPERLY SECURE HIS TRAIN.  Irrespective of any rules and instructions he may have complied with - if the train moved, it was not SECURED.

His faulty decision making and actions taken started the movement of the Swiss Cheese Holes to end up in the fireball that was Lac Megantic.

[tree68]

BaltACD

There was only ONE man who could have stopped the Swiss Cheese Holes from ever getthing the opportunity to line up. 

Yep.

[Euclid]

Overmod

 

Euclid

So that means the firemen are responsible for the disaster?

 

 

The firemen SHARE responsibility for the disaster.  Had they not shut the locomotive down improperly and incompletely, in fact had they continued into the locomotive and shut down the battery connection (as firemen usually do with automobile fires) I believe the brakes would have been applied.

 

No one is "blaming" them for "causing" the accident.  But without them doing what they did and didn't do, it would almost certainly not have occurred.  To see that distinction, I think you may need to ponder the koan more carefully.

 

What were [the firemen] supposed to do?  Was it their responsibility to track down the highest authority of MM&A to let them know?  They did officially notify the corporation through the MM&A employees who were directly involved.  If those employees were not competent enough to act responsibly, that is not the fault of the fire department.

 

 

If I remember correctly, one of the reasons for 'haste' in hitting the unit emergency switch was paranoia about an EXPLODING OIL TRAIN that had visibly caught fire.  Evidently they thought that the danger was over when the flames were out.

 

"Should they have known" that the train brakes were hanging on a running locomotive?  They couldn't know.  I find it hard to believe those folks at Farnham didn't know standard procedures, though, and those people clearly understood there were no running engines on a train largely secured by its independent brake.  

In my opinion, the 'blame' lies with not connecting dots, and can't be laid to any 'one' person or group.  On the other hand, of all the groups that night most conscious of the awful hazard that train represented, firemen would be at the top of the list, and confirming that train's security ... not just passing the buck in the middle of an American-holiday night ... perhaps ought to have been more of a priority than it proved to be.

 

So you believe the firemen SHARE responsibility for the disaster but nobody is blaming them for causing it.  And you come to this conclusion due to their failure to disconnect the battery in order to cause the locomotive to apply the brakes.  Yet, they shut off the fuel which stopped the engine.  The fire self-extinguished without the engine running.  The firemen determined that the fire was out, so they left.  The three contact persons for MM&A were informed of these details.

But you believe that the firemen were negligent, (but not blamed) and thus share the responsibility for the disaster because they left without making sure that the train was secured against movement on the grade, even though, at the time, the train was secured.  So once they disconnected the battery to cause the brakes to apply, how should they have made certain that action caused the brakes to apply? 

It is noteworthy that Mr. Burkhardt, CEO of the MM&A, accused the fire fighters of “causing” the derailment and multiple deaths along with a great amount of property damage by what he referred to as “tampering” with the locomotive and thus causing the brakes to release on the train. He also seemed to believe the firemen should have been blamed for that. But for all we know, he may have just wanted to share a little of the responsibility with the firemen.   

Yet, all that the firemen had done was shut off the fuel which was part of the instructions for action that the fire department had shared with MM&A on earlier occasions; in anticipation of possible future emergencies that would require the response of the fire department. And yet you believe that the firemen should have disconnected the battery to cause a brake application and then gone back in the train to check and make sure the brakes were adequately pressed against the wheels.  Maybe they should have started up another engine and done a proper push/pull test to make sure the brakes they set would hold the train.   

You also say that you are of the opinion that the blame lies with not connecting the dots, and that can’t be laid to any one person or group.  Is there anyone blaming a particular person or group for not connecting those dots?  Perhaps they are just all sharing the responsibility.  If someone had connected the dots, would they all have been connected in a line like a string of tank cars?  

[zugmann]

BaltACD

His faulty decision making and actions taken started the movement of the Swiss Cheese Holes to end up in the fireball that was Lac Megantic.

I woudl argue the holes were starting to line up. He jsut threw it off hte proverbial (and literal?) precipice. 

[BaltACD]

zugmann

 

BaltACD

His faulty decision making and actions taken started the movement of the Swiss Cheese Holes to end up in the fireball that was Lac Megantic. 

I woudl argue the holes were starting to line up. He jsut threw it off hte proverbial (and literal?) precipice. 

His decisions and inactions lined up all the Swiss Cheese Holes except one.  When the running locomotive caught fire and the FD extinguished it and shut the engine down - the last Swiss Cheese Hole 'clicked' into place and shortly there after the train was off to the races.

[tree68]

Bucky - a basic tenet of incidents like these is that there are a number of factors, and that removing any of those factors would likely have prevented the incident from occurring.  

So run down that list of factors that the Canadian transport board assembled and ask yourself - if this factor had been properly handled, would the incident have occurred?  This is an exercise for you and you alone.  

When you're done, you'll probably see that a lot of people had a piece of this, and that many of the factors are interlocking (ie, if the locomotive had been properly maintained, there probably wouldn't have been a fire).  

In the end - not enough hand brakes were set...

 

[MMLDelete]

The object of the game is not to blame, rather it's to make railroading safer going forward.

Yes, if enough brakes had been set, the accident would not have happened. But there is certainly value in seeing what steps, had they been taken beforehand, would have made things more safe IF by chance a Harding came along later and made a bad decision.

[MMLDelete]

I don't understand why a derail could not be set. Can someone explain this in layman's terms? It seems like in this situation like this, setting a derail would be a no-brainer.

[BaltACD]

Lithonia Operator

I don't understand why a derail could not be set. Can someone explain this in layman's terms? It seems like in this situation like this, setting a derail would be a no-brainer.

Have you ever handled a 'portable derail'?  As a single individual?  How much weight can you safely control with your body on the walking conditions that exist on a railroad right of way on Main Line trackage?

[MMLDelete]

BaltACD

Have you ever handled a 'portable derail'?

Nope. Haven't seen a whole lot of derails in person, period, to be honest.

Isn't there a type of derail that can be permanently installed, but is switchable beween derail and clear? I was thinking there existed such a device, and that one should have been installed down the grade at a point beyond the length of the longest trains. (The train would always be uphill from the derail.)

I guess the flaw in my thinking is that it would require the engineer to walk perhaps 2 miles round-trip to set the thing, then the next engineer repeat that hike to leave. But couldn't the derail be near some (private) road, and this whole shuffle could be part of a routine involving the crew van picking up or bringing the engineers. IE: drive to and from this theoretical derail.

(I thought I saw some discussion about how rules/laws prevent the use of a derail on a main, or something like that, and that was given as a reason for not having one. But I didn't understand what that was all about. If a train is routinely parked on the main, no one can be expecting some other train to come rolling along and derail.)

[adkrr64]

Putting a derail on a main would be quite unusual, though I don't know if it would violate any sort of FRA or TC regulation. Perhaps Mudchicken can educate us.

There are many different types of derails, including ones that are actuated with something like a switch stand. So there are ways to avoid the "flip over" style, which can be fairly heavy, though even those should be well within the type of physical work expected of a railroader.

If the idea is to put a train on the ground if there is unintended movement, a regular main line switch, facing point in the direction of downhill travel, could be lined against the main when the train is parked, and the track from the reversed switch being stub ended. The location of the switch would necessarily need to be close to where the train  is parked, not halfway down the hill.

[Overmod]

Lithonia Operator

I don't understand why a derail could not be set. Can someone explain this in layman's terms? It seems like in this situation like this, setting a derail would be a no-brainer.

First, any 'portable' derail might not be effective; the only effective kind being like switch points.  As noted the portable devices are very heavy, and the walk to place and retrieve one is basically the same as the walk to inspect one side of a set and release of the automatic.

I recall specific discussion of why a derail is not placed in a main track in the TSB's report, although I cannot check it from here.   There are obvious great dangers from failure, including the usual issues about incomplete locking or points being 'picked' under a train.  In any case the use of such a derail is itself an operational catastrophe, becoming an ecological catastrophe should even a slight breach releasing nondegassed crude then occur.

[Euclid]

tree68

Bucky - a basic tenet of incidents like these is that there are a number of factors, and that removing any of those factors would likely have prevented the incident from occurring.  

So run down that list of factors that the Canadian transport board assembled and ask yourself - if this factor had been properly handled, would the incident have occurred?  This is an exercise for you and you alone.  

When you're done, you'll probably see that a lot of people had a piece of this, and that many of the factors are interlocking (ie, if the locomotive had been properly maintained, there probably wouldn't have been a fire).  

In the end - not enough hand brakes were set...

 

 

Yes I understand exactly what you mean.  I have looked at the TSB wheel of 18 causes and contributing factors several times with the intent of finding the items that, if were not factors in this disaster, would have thus prevented it.  That concept seems simple to a point.  One that certainly fits that criterion is “Insufficient hand brakes.”  Also, the one called “Train left unattended on hill” would certainly seem to qualify as a point that, had it not happened, would have rendered the runaway impossible. 

Other points such as, “Improper hand brake test” are not as clear.  There is no guarantee that had the engineer done a proper hand brake test; he would have set enough hand brakes to hold the train.  For instance, the engineer could have set insufficient hand brakes, and then done a push/pull test with the independent air brakes released, which would be a proper test.  Then say he found the train moved while he was doing the proper test.   

But, upon learning that result, instead of going back and setting more hand brakes, he might have just decided to set the independent brakes and rationalized that even though the test failed, it was only at the margin, and so the independent brakes will be the added assurance of holding the train.  In that case, he would have done a proper hand brake test, even though the test failed.  Then he mitigated the failure by applying the independent brakes.  Thus I conclude that the STB wheel chart factor of “Improper hand brake test” was not necessarily an item that, if removed from the chart, would have prevented the runaway.

Also, I get bogged down with some of the other bullet points on the wheel.   Some are very explicit and yet some are impossible to quantify.   Then there is the difference between the terms “cause” and “contributing factors.”  Then there is also the term “blame.”  All three of these terms have undefined elements and implications.  They each also have an edginess of controversy.  Note that the TSB uses the first two of those terms almost interchangeably. 

And also, people don’t like the term, “blame” because they feel like using it will brand them as a hater.  So there is a modern cultural tendency to say that nobody is to blame or that we all share the blame.  Often you hear people assert that the point is not to pin blame as though that would be unfair and hurtful.

Along these lines of new sensitivity I feel that, in this case and many others lately, there is a trend toward the conclusion that all accidents have more than one cause.  Indeed this is a firewall that prevents one person from taking the blame.  So it is because of this trend that I am skeptical of the idea that there is NEVER a single cause, as the TSB says.  Never?  I hear lots of experts spouting this new-age dogma.  And I sense it easily in the TSB report and in NTSB reports lately. 

But fixing blame is more deeply ingrained in the railroad culture than probably any other industry. Lots of things in railroading can and do go wrong, and the industry wants a rule forbidding each one from being caused by an employee.  So they look for the one cause of an accident.  They are the last to conclude that everyone was to blame.

But back to the wheel of 18 factors, some of them are also so broad that their occurrance would have to not be present, in order for the Lac Megantic disaster to have been avoided.  One example would be “Not effectively managing risks.”   In other words, if a train ran away because it was improperly secured, it has to follow that some risks were not properly managed. 

So I am working on a little project to unpack the wheel of 18 factors provided by the TSB, and will post it soon.  

[tree68]

Euclid

So I am working on a little project to unpack the wheel of 18 factors provided by the TSB, and will post it soon.  

When you do, post it as a new thread, lest folks think there's further information about the incident in Tamaqua.

[MMLDelete]

tree68

 

 

Euclid

So I am working on a little project to unpack the wheel of 18 factors provided by the TSB, and will post it soon.  

 

 

When you do, post it as a new thread, lest folks think there's further information about the incident in Tamaqua.

 

I plead guilty for steering this toward Megantic. I wound up making a thread about a relativemy insignificant derailment morph into a discussion of one of the most horrific tragedies in railroad history.

Sorry.

[Flintlock76]

Um, does anyone remember the RBMN Tamaqua derailment?

Anyone know what caused it?  I think we know enough about Lac-Megantic by now.

[SD70Dude]

Flintlock76

I think we know enough about Lac-Megantic by now.

But we don't know who to fine, who to jail, and who to hang.  Isn't that what really matters?

If only there had been a criminal trial, perhaps some answers could have been found......

[Flintlock76]

SD70Dude

But we don't know who to fine, who to jail, and who to hang.  Isn't that what really matters?

Well barring any of the above burning in effigy is always an option.  

[SD70Dude]

Flintlock76

SD70Dude

But we don't know who to fine, who to jail, and who to hang.  Isn't that what really matters?

Well barring any of the above burning in effigy is always an option.  

That would only change the debate to what degree of burns they deserve.  

I'll contribute a model of the lead locomotive, but it has already been torched as part of the authentic GE detailing process.

[GERALD L MCFARLANE JR]

tree68

 

Lithonia Operator

Meanwhile back at the ranch, does anyone know if RBMN cleaned up their derailment? 

As I recall, someone said they could still get traffic through.  If the cars were essentially stored there, with not immediate use (ie, ballast cars, etc) and the track is not essential for daily ops, they probably aren't in a rush to clean things up.

Or, it's done.  

Since the RBMN still moves anthracite coal and those are mostly moved in RBMN marked hoppers I'm pretty sure that cut of cars aren't for ballast or other uses, they're coal cars and that's what the RBMN uses them for, they just might have been stored there temporarily awaiting the next load.

[Paul Milenkovic]

Euclid

 

 

Paul Milenkovic

I would not make a rule that the fire department cannot press the fuel cutoff button to put out a fire on an aging General Electric locomotive.  Again, the burden should be on the locomotive design to not release brakes under those circumstances.  Why would you want a locomotive to start rolling if it quit?

 

 

 

There was no such rule.  As I recall, there was a rule telling the firemen to use the emergency fuel cutoff as the first move, and that it what they did. It immediately shut off the engine and stopped the fire, which was mostly in the exhaust manifold.  A worker from MM&A was there on scene with the firemen to act as their representative for the railroad. 

All of the information about the fire, including the effort to extinguish it, and the fact that the one locomotive that had initially been left running and was on fire; and had been left shut down after the fire was put out—  all of that information was conveyed to the two MM&A supervisors before the firemen and the company rep left the scene.    

The burden, as you say, is not on the locomotive design, but rather, it is on the car hand brakes.  Setting adequate hand brakes is the only allowable means of securing a train.  Any securement reliance on air brakes, either independent or automatic, is strictly forbidden by rules and laws.  If that requirement had been followed, there would have been no problem in shutting down the engine and losing air pressure.

The issue of technological deficiency is the manual hand brake on railcars.  Its concept dates back to the 1800s.  Securing a big train on a steep grade can require setting 50-75 hand brakes by people walking the train.  Ideally, there would be one button you could push that would set all those hand brakes automatically with a controlled power source. 

 

 

"There was no such rule."

Don't you think I know that?  There was indeed no such rule, but that didn't stop railroad management from pointing fingers at the fire fighters.

"I would not make a rule."  So what plausibly, could a person infer that I meant by that?  There is at present no such rule, and I would not support making a rule to prevent fire fighters from pressing the emergency fuel  cutoff.  Fire fighters should not have to know about the technical details of train braking systems.   Press the cutoff and put out the fire, already.

Note that I don't call them firemen.  I am not being politically correct, here, when a "fireman" historically is a railroad crew member.  To call the non-railroad-employee fire fighters "firemen" is creating confusion as to roles of the different people involved.

So why am I taking about rules I would make and rules I would not make?  I am looking towards preventing the next disaster.

"Setting adequate hand brakes is the only allowable means of securing a train.  Any securement reliance on air brakes, either independent or automatic, is strictly forbidden by rules and laws.  If that requirement had been followed, there would have been no problem in shutting down the engine and losing air pressure."

OK, I get that.  Air brakes are not a parking brake.  To use an aviation analogy,  the ramp crew puts chocks under the wheels of the airliner.

"Securing a big train on a steep grade can require setting 50-75 hand brakes by people walking the train."

To continue the aviation analogy, do the airlines park their planes on steep inclines and secure them with chocks under those conditions?

"Ideally, there would be one button you could push that would set all those hand brakes automatically with a controlled power source."  

Isn't that a form of power brake, which is against the rules to secure a train?  Why are these power-actuated "hand brakes" OK, but it is not OK to consider design changes to make the air brakes systems reliable?

Setting 50-75 hand brakes by "people" walking the train?  There was only one crew member on that train.  How long does setting 50-75 hand brakes take?  One hour?  Two hours?

This accident suggests that the use of railroads to transport crude oil is from a safety standpoint Boeing 737 Max-level of broken.  Rules and rules, what are rules?  The whole technology and the whole rulebook needs to be rewritten if the lapse of the single train crew member can result in such an outcome.

[Paul Milenkovic]

Let's pose the question this way.

This was not the first trip made by this train?  Where was it parked during previous crew changes?  How is that train habitually secured?  Was the train secured with an adequate number of hand brakes on all of those occasions, or was it blind luck that this train didn't crash until that fateful night?

[Euclid]

tree68

 

Euclid

So I am working on a little project to unpack the wheel of 18 factors provided by the TSB, and will post it soon.  

 

 

When you do, post it as a new thread, lest folks think there's further information about the incident in Tamaqua.

 

Yes, that would be the plan.

[Euclid]

Paul Milenkovic

 

Euclid

 

 

Paul Milenkovic

I would not make a rule that the fire department cannot press the fuel cutoff button to put out a fire on an aging General Electric locomotive.  Again, the burden should be on the locomotive design to not release brakes under those circumstances.  Why would you want a locomotive to start rolling if it quit?

 

 

 

There was no such rule.  As I recall, there was a rule telling the firemen to use the emergency fuel cutoff as the first move, and that it what they did. It immediately shut off the engine and stopped the fire, which was mostly in the exhaust manifold.  A worker from MM&A was there on scene with the firemen to act as their representative for the railroad. 

All of the information about the fire, including the effort to extinguish it, and the fact that the one locomotive that had initially been left running and was on fire; and had been left shut down after the fire was put out—  all of that information was conveyed to the two MM&A supervisors before the firemen and the company rep left the scene.    

The burden, as you say, is not on the locomotive design, but rather, it is on the car hand brakes.  Setting adequate hand brakes is the only allowable means of securing a train.  Any securement reliance on air brakes, either independent or automatic, is strictly forbidden by rules and laws.  If that requirement had been followed, there would have been no problem in shutting down the engine and losing air pressure.

The issue of technological deficiency is the manual hand brake on railcars.  Its concept dates back to the 1800s.  Securing a big train on a steep grade can require setting 50-75 hand brakes by people walking the train.  Ideally, there would be one button you could push that would set all those hand brakes automatically with a controlled power source. 

 

 

 

 

 

"There was no such rule."

Don't you think I know that?  There was indeed no such rule, but that didn't stop railroad management from pointing fingers at the fire fighters.

"I would not make a rule."  So what plausibly, could a person infer that I meant by that?  There is at present no such rule, and I would not support making a rule to prevent fire fighters from pressing the emergency fuel  cutoff.  Fire fighters should not have to know about the technical details of train braking systems.   Press the cutoff and put out the fire, already.

Note that I don't call them firemen.  I am not being politically correct, here, when a "fireman" historically is a railroad crew member.  To call the non-railroad-employee fire fighters "firemen" is creating confusion as to roles of the different people involved.

So why am I taking about rules I would make and rules I would not make?  I am looking towards preventing the next disaster.

"Setting adequate hand brakes is the only allowable means of securing a train.  Any securement reliance on air brakes, either independent or automatic, is strictly forbidden by rules and laws.  If that requirement had been followed, there would have been no problem in shutting down the engine and losing air pressure."

OK, I get that.  Air brakes are not a parking brake.  To use an aviation analogy,  the ramp crew puts chocks under the wheels of the airliner.

"Securing a big train on a steep grade can require setting 50-75 hand brakes by people walking the train."

To continue the aviation analogy, do the airlines park their planes on steep inclines and secure them with chocks under those conditions?

"Ideally, there would be one button you could push that would set all those hand brakes automatically with a controlled power source."  

Isn't that a form of power brake, which is against the rules to secure a train?  Why are these power-actuated "hand brakes" OK, but it is not OK to consider design changes to make the air brakes systems reliable?

Setting 50-75 hand brakes by "people" walking the train?  There was only one crew member on that train.  How long does setting 50-75 hand brakes take?  One hour?  Two hours?

This accident suggests that the use of railroads to transport crude oil is from a safety standpoint Boeing 737 Max-level of broken.  Rules and rules, what are rules?  The whole technology and the whole rulebook needs to be rewritten if the lapse of the single train crew member can result in such an outcome.

 

The issue is of securement reliability is not whether brakes are powered or manual.

Air brakes are not supposed to be used for securement because of the fact that they can lose air for a number of reasons, and that makes them unreliable.  Hand brakes are considered to be reliable because they are mechanical and will not release on their own like air brakes can if the air leaks off.  But hand brakes can be released by vandals, so they are not infallible if someone is determined to release them.

However, for securement purposes, air brakes could be made with mechanical locks that are held in release with air pressure, and then the locks could be set by the release of that air pressure that holds the mechanical locks in release. 

This would leave cars secured by brakes set and held by mechanical locks, which could not be released by vandals or release on their own like current air brakes can. 

[Overmod]

Euclid

However, for securement purposes, air brakes could be made with mechanical locks that are held in release with air pressure, and then the locks could be set by the release of that air pressure that holds the mechanical locks in release.  This would leave cars secured by brakes set and held by mechanical locks, which could not be released by vandals or release on their own like current air brakes can.

While Euclid is correct in thinking not all "power" brakes would be illegal to leave unattended, he has a somewhat Colinesque grip on the necessary technology, although he has discussed reasonably good solutions in other past threads.  

The reason air brakes cannot be used as securement is ancient: they have no positive action.  We can go back before the advent of the Loughridge chain brake to see the difference; it is similar to the issue with trailer surge braking vs. spring brakes.  When the pressure in the system is lost, there is no brake effort, and the original Power Brake Law recognized this.

What is required is a mechanical brake, acting on the foundation as a 'motorized' brake wheel would, with an appropriate mechanical release that does not require great force (like that you may have needed to get a steering-column lock in your car to release if you've parked on a hill with your wheels turned!) to get started.  If you're concerned with vandalism this could be locked, or coded, at least beyond the meddling powers of nondetermined vandals.  In Euclid's 'parking brake' system a couple of years ago, he made this a motorized release as well as application ... and zug recognized that locomotive equipment of just this kind is currently marketed, and probably adapted to this purpose.  

Note that no form of 'spring brake', as used on trailers, has adequate strength to keep railroad cars secured without at the same time posing dramatic risks if actuated at the wrong time, e.g. when moving at speed in a train.

Likewise, no system using 'fluid power' to apply the brake shoes or pads is suitable, as pressure leaks produce the same problem low air in cylinders does.  What is needed is not positive locking of fluid-power valves, it is positive locking of shoes in contact with wheels or other contact surfaces, and that implies a mechanism.

The problem of course is that to install such a system, assuming it could be designed with reasonable robustness and longevity, together with the necessary trainline or radio equipment plus power for the motors and telltale system, would cost a reasonable percentage of ECP conversion, which has far more benefits for train-handling than automatic blind securement would.  In addition, after application a 'single crewman' would still have to walk the train to verify the mechanical securement, and probably again to verify an automatic release as even one dragging brake may lead to "consequences" and the effect of power brakes on a given car's foundation may have to be determined after all 'handbrake' systems are thoroughly released...

[zugmann]

Euclid

However, for securement purposes, air brakes could be made with mechanical locks that are held in release with air pressure, and then the locks could be set by the release of that air pressure that holds the mechanical locks in release. 

Can I  still kick cars?

[Overmod]

zugmann

Can I  still kick cars?

Theoretically, in his system, you could 'override' the automatic engagement by winding off the 'mechanical engagement' -- obviously it won't be a spring brake of any kind, for reasons we've beaten to death, and if it's a mechanical lock holding air pressure you could 'selectively' bleed or bail that off before kicking.

On a more "proper" system, the premise would be that (as in the locomotive system you found) it would be possible to engage 'parking brakes' on the mechanical foundation of cars or locomotives with some reasonable command, and then release them under power (with the inherent characteristic that they then stay reliably locked off -- as with other kinds of properly-designed parking brake).

Presumably a cut of cars that is going to be used to pull cars for 'kicking' would have its securement handled 'appropriately' when yarded.  In the absence of individual 'parking-brake release' a crew would simply wind off the manual brake handle and then klck as appropriate (now with the ability to use the battery reserve to re-apply the securement once the car is positioned, if wanted, or have it apply 'automagically' as the cable is connected between cars or radio link is verified or whatever)

A sensible system will have some kind of telltale on the car that a switching crew could use to determine whether the securement is applied or released without having to physically get on the car to confirm it.  I at least think the telltale for mechanical engagement shouldn't be the same as that for having handbrakes wound on.  Euclid may of course differ.

[n012944]

Flintlock76

Um, does anyone remember the RBMN Tamaqua derailment?

Anyone know what caused it?  I think we know enough about Lac-Megantic by now.

 

 

This.

 

Here is the thread for Lac-Megantic,

http://cs.trains.com/trn/f/111/t/218974.aspx?page=15#2422042

The topic was beaten to death on it, by a poster who changed their screen name.  I see while he may have changed his/her name, they have not change their style.

 

[BaltACD]

Paul Milenkovic

Let's pose the question this way.

This was not the first trip made by this train?  Where was it parked during previous crew changes?  How is that train habitually secured?  Was the train secured with an adequate number of hand brakes on all of those occasions, or was it blind luck that this train didn't crash until that fateful night?

I SUSPECT -

Prior trips by the Engineer of this trip were handled in the same manner as the fateful trip.  All the Swiss Cheese Holes that lined up from his failures to properly secure the train had lined up EXCEPT for the locomotive catching fire and being shut down by the responding Fire Department.

Othere Engineers handling these shipments MAY have properly secured their trains, or they may have done the same thing as the Engineer of the fateful trip - WE HAVE NO WAY OF KNOWING.  Prior trips, to our knowledge, were all done successfully without a run-a-way.

[mudchicken]

Another one of these "holes" is operating practices versus FRA rule. FRA rules and safety rules are usually a reaction to an incident or series of incidents.

Most railroads would see trains regularly tied down on the main in the same place as a call for the location of a siding, preferably with no crossings and a sag -or- draped over a hill like here. Nothing on that in the FRA rules. The Arriba CO tragedy had a siding, but no derails (CRIP operating practice for passing sidings - there are derails there now) .... Not as cut and dried as some want to think on this forum.

 

[tree68]

mudchicken

Another one of these "holes" is operating practices versus FRA rule. FRA rules and safety rules are usually a reaction to an incident or series of incidents.

Have to change FRA to whatever the Canadian equivalent is, but otherwise spot-on.

[Euclid]

Overmod

 

zugmann

Can I  still kick cars?

 

 

Theoretically, in his system, you could 'override' the automatic engagement by winding off the 'mechanical engagement' -- obviously it won't be a spring brake of any kind, for reasons we've beaten to death, and if it's a mechanical lock holding air pressure you could 'selectively' bleed or bail that off before kicking.

 

On a more "proper" system, the premise would be that (as in the locomotive system you found) it would be possible to engage 'parking brakes' on the mechanical foundation of cars or locomotives with some reasonable command, and then release them under power (with the inherent characteristic that they then stay reliably locked off -- as with other kinds of properly-designed parking brake).

Presumably a cut of cars that is going to be used to pull cars for 'kicking' would have its securement handled 'appropriately' when yarded.  In the absence of individual 'parking-brake release' a crew would simply wind off the manual brake handle and then klck as appropriate (now with the ability to use the battery reserve to re-apply the securement once the car is positioned, if wanted, or have it apply 'automagically' as the cable is connected between cars or radio link is verified or whatever)

A sensible system will have some kind of telltale on the car that a switching crew could use to determine whether the securement is applied or released without having to physically get on the car to confirm it.  I at least think the telltale for mechanical engagement shouldn't be the same as that for having handbrakes wound on.  Euclid may of course differ.

 

What I was proposing in our last discussion of my securement brake a while back was not a motorized brake, a spring brake, or a hydraulic brake.  It is the basic conventional car air brake with the same cylinder, and valve.  But there are some modifications and additions to the rigging.  It does not change the basic pneumatic power of the brake existing system. 

The reservoir can be bled as usual, leaving the brakes released without air, and switched without air as usual.  The added features are in the same sort of loose fitting steel rods, levers, and pneumatic cylinder art of conventional car brake systems.  However, it does require a second trainline, although of a smaller diameter.

With this system, an engineer parking a train on a grade would set the automatic air, and then bleed the straight air locking cylinders back to the locomotive cab through the second trainline.  The locks would set by spring force just as the conventional pneumatic power brake cylinder releases by spring force.

So all the brakes on the train would be locked as securely as with handbrakes, but unlike the ease of vandals releasing handbrakes, this locked feature of conventional air brakes could only be released by recharging it along with recharging the regular trainline. 

So the entire train securement on a grade could be applied to all cars in the train from the cab within a few minutes.  And the release would also be made from the cab in an equally short time.    

But it is highly unlikely that the need for a second trainline to pneumatically charge and release the lock would be accepted by the industry.  This gets into the same issue as with ECP brakes or new fully automatic couplers.  They too are unlikely to adopted due to the loose car system that makes the conversion non-standard and thus requiring a dual system during the conversion cycle.   

However, if this brake locking feature were combined with ECP brakes, it opens the door to the basic ECP brake trainline for air being also used for the charging function of releasing the brake locks.  This would be feasible because the ECP air brake trainline is  not used for pneumatic control like the current conventional trainline is. 

So this could eliminate the need for a second trainline to support this brake lock system if it were executed with current fully pneumatic brakes. 

[CSSHEGEWISCH]

Bucky apparently does not believe in the KISS method.  This seems like an overly complicated and maintenance-intensive system to replace setting handbrakes manually.

[BaltACD]

CSSHEGEWISCH

Bucky apparently does not believe in the KISS method.  This seems like an overly complicated and maintenance-intensive system to replace setting handbrakes manually.

Bucky's 'labor saving' plans are the Rube Goldberg machines of the railroad industry.

[ChuckCobleigh]

BaltACD

Bucky's 'labor saving' plans are the Rube Goldberg machines of the railroad industry.

Heh!™

[Euclid]

CSSHEGEWISCH

Bucky apparently does not believe in the KISS method.  This seems like an overly complicated and maintenance-intensive system to replace setting handbrakes manually.

 

KISS is relative to the complexity of the task.  Just look at the engine room of a modern ship and tell me how simple it should be.  Do you think the average person would tour that engine room and be impressed with how simple it is?

The current method of walking car to car and winding up a hand winch dates back to the beginning of the railroad industry when trains were only a few cars long.  Now they are 200 cars long and securing them on a grade can require dozens if not over 100 handbrakes to be set by climbing ladders and winding up winches.  Is that simple enough?  If you looked around for the most outdated practice in the railroad industry, that would be it.

It is the low hanging fruit begging for improvement.  But it has been that way forever, and continues today because the industry hides behind the KISS mantra.  No solution has been simple enough, so good for them.  Meanwhile trains continue to run away causing death and destruction like they always have due to the shortcomings of the current manual hand brake.  But at least it is simple.

There are lots of engineering ideas for power handbrakes that bring the securement feature under the direct power control of the crew just like every other facet of train operation.  Many of them use electric winches, gear boxes, power source, switching, relays, and control information feedback.  They seem a whole lot more complicated than what I propose.  They seem like they would be a $10-15,000 parking brake by the time they were perfected for railroad application. 

So, to be fair, if a replacement for the railcar handbrake is needed, show me a proposal that is simpler than what I have described. 

[tree68]

Euclid

So, to be fair, if a replacement for the railcar handbrake is needed, show me a proposal that is simpler than what I have described. 

What we already have is pretty simple.  

[BaltACD]

Euclid

 

CSSHEGEWISCH

Bucky apparently does not believe in the KISS method.  This seems like an overly complicated and maintenance-intensive system to replace setting handbrakes manually. 

KISS is relative to the complexity of the task.  Just look at the engine room of a modern ship and tell me how simple it should be.  Do you think the average person would tour that engine room and be impressed with how simple it is?

The current method of walking car to car and winding up a hand winch dates back to the beginning of the railroad industry when trains were only a few cars long.  Now they are 200 cars long and securing them on a grade can require dozens if not over 100 handbrakes to be set by climbing ladders and winding up winches.  Is that simple enough?  If you looked around for the most outdated practice in the railroad industry, that would be it.

It is the low hanging fruit begging for improvement.  But it has been that way forever, and continues today because the industry hides behind the KISS mantra.  No solution has been simple enough, so good for them.  Meanwhile trains continue to run away causing death and destruction like they always have due to the shortcomings of the current manual hand brake.  But at least it is simple.

There are lots of engineering ideas for power handbrakes that bring the securement feature under the direct power control of the crew just like every other facet of train operation.  Many of them use electric winches, gear boxes, power source, switching, relays, and control information feedback.  They seem a whole lot more complicated than what I propose.  They seem like they would be a $10-15,000 parking brake by the time they were perfected for railroad application. 

So, to be fair, if a replacement for the railcar handbrake is needed, show me a proposal that is simpler than what I have described. 

When you mention POWER, unnecessary complexity follows.  There is nothing simpler than manual labor.  Applying handbrakes require manual labor.  Brakemen/Conductors are reasonably well paid for their efforts that are required by the Book of Rules and Timetable Special Instructions.

[Randy Stahl]

I often avoid conversations about Megantic for obvious reasons. I often remember that day. I remember checking and rechecking my phone to see if I had missed any calls. None of us were out of hand that night. I wasn't doing anything at all. In fact I was well known for always answering my phone. It is almost a certainty that if I had been called that night there is an excellent chance that wreck would not have happened and 47 people would still be alive. But no one called me until it was too late.

I wonder how many experts here blame me ? 

[SD70Dude]

Randy,

No expert worthy of the name would place any blame on you. 

Once again, thank you for participating in the past discussions on this forum, and for continuing to check in.

[Shadow the Cats owner]

I got to asking several of the mechanics at the shop here how they could solve the issue that the railroads have with handbrakes and then when air bleeds off.  One went have they not heard of the R12 valve we use in the OTR industry.  It is a pressure sensing valve used as standard equipment on our trailers that if air pressure gets to low automatically will apply the 30/30 chambers on the trailers.  I asked him how he would rig it up to work on a railroad car that needs to be switched.  He went put the parking brake spring into the cylinder use the R12 as the sensor with a seperate pressure chamber where if it gets to low it could override the brakes and keep them applied.  For switching he would use the brake bleed off rods to capture the spring that applies the brakes or closes a valve that feeds the R12 line the pressure reading.  That way the car could be moved for switching in yards.  The failsafe comes in when it is dropped and dynamited even if someone tried to use the bleed off if the brakes where set before the rod was pulled that car will not move.  So even a vandal could not get it to move.  Also in an emergency situation where a train was forced to stop on a hill due to loss of air the brakes would not release until all air pressure is recovered from an emergency application preventing runaways like the one that hit the CP last year and for what happened in LaMagnetic this system would have literally applied every brake on the train from the EOT slowly draining the air tanks and kept it from moving an inch.  

 

He thinks the cost per car would be around 5 to 6 hundered bucks for parts then the labor for the installs.  The mechanic in question is an ASE master been here for 25 years knows more about air brakes than I want to know can literally rebuild anything brake related in our fleet and was the driving force for us to switch to disk instead of drum brakes on the entire fleet including retrofitting the older trailers.  So if he says this would work I would take him at his word he literally just redid the brakes on a truck for an Owner Operator that the dealership said was going to cost that person 4 grand in parts and he found the problem and fixed it for less than 2 grand for everything.

[Euclid]

BaltACD

When you mention POWER, unnecessary complexity follows.  There is nothing simpler than manual labor.  Applying handbrakes require manual labor.  Brakemen/Conductors are reasonably well paid for their efforts that are required by the Book of Rules and Timetable Special Instructions.

All machinery is complex compared to no machinery.  But complexity alone does not mean that it is more complicated than necessary.  KISS means to eliminate complexity that is unnecessary to do the job.  If getting the job done pays for necessary complex machinery, the complexity is justified. 

 

[Electroliner 1935]

We need more like him. The problem as I see it is overcoming the inertia caused by the bean counters needing a clear economic case that shows a positive number for doing what needs to be done. The costs of many hours of men setting and releasing hand brakes, coupling air hoses and how many deaths and cleanup costs for accidents against the costs to retrofit all of the existing equipment. If it could be shown that the existing equipment can not be operated in severe weather safely, (I don't know how many run away trains it takes to make that case) then it might give more justification. And since the holes in the swiss cheese don't line up very often, it will take a long time to make the case. 

[Convicted One]

Randy Stahl

I wonder how many experts here blame me ? 

The only thing I blame you for, is not posting here often enough. 

As far as the expertise of internet "experts" goes, I hope you don't let that bother you much.

Frequently, when you see people disagreeing with others, it's just a mechanism for them to inject "hey, I know stuff too" into a conversation.

[zugmann]

Shadow the Cats owner

  So if he says this would work I would take him at his word he literally just redid the brakes on a truck for an Owner Operator that the dealership said was going to cost that person 4 grand in parts and he found the problem and fixed it for less than 2 grand for everything.

Honest question - Does he have any experience in the railroad side of things? 

If we're going to start redoing brake systems - I think we should just go full ECP.  But that's my opinion...

[Euclid]

Shadow the Cats owner

One went have they not heard of the R12 valve we use in the OTR industry. It is a pressure sensing valve used as standard equipment on our trailers that if air pressure gets to low automatically will apply the 30/30 chambers on the trailers. I asked him how he would rig it up to work on a railroad car that needs to be switched. He went put the parking brake spring into the cylinder use the R12 as the sensor with a seperate pressure chamber where if it gets to low it could override the brakes and keep them applied.

I gather that the 30/30 chambers you mention are the equivalent of the brake application cylinders on railcars.  It sounds like the R12 valve senses low reservoir pressure and there is a second or emergency reservoir from which the R12 valve feeds air into the 30/30 chambers if the main reservoir is sensed  by the R12 valve to be too in pressure. 

Ask your mechanic how he would overcome the problem of the 30/30 chambers having defective seals that allow their activation charge to leak off as it is applied. I would guess that his answer would be that you must inspect and maintain the 30/30 chambers to prevent them from leaking. 

Correspondingly, if railcar brake cylinders have worn out cylinder packing, they will leak when charged for air brake application.  They may hold enough air to stop the train, but then leak down enough to release.  Then the stopped train runs away. 

As railcar cylinder packing wears out, it first becomes evident at the coldest temperatures because the packing material naturally loses its resiliancy as temperature drops.

[Shadow the Cats owner]

We use a synthic rubber packing between the spring chamber and the main brake chamber.  Then if the that membrane fails or the packing breaks the spring itself breaks due to the construction of it.  Which causes a leak.  The r12 can sense from any pressure chamber that is plumbed into it.  The railroads could feed both the Emergnecy and main brake res pressure chambers into it. We also have leaking brake chambers all the time that show up.  For us a leaking brake chamber is no problem.  We can fix it in less than 20 mins normally.  But then we do tend to maintain things better than railroads it seems.  Most of my bosses trailers see the shop at least 1 time every 2 months.  Most of our trucks are in the shop every 2-3 weeks for at least a grease job.  If they get written up we fix them.  

[Euclid]

Shadow the Cats owner

We use a synthic rubber packing between the spring chamber and the main brake chamber.  Then if the that membrane fails or the packing breaks the spring itself breaks due to the construction of it.  Which causes a leak.  The r12 can sense from any pressure chamber that is plumbed into it.  The railroads could feed both the Emergnecy and main brake res pressure chambers into it. We also have leaking brake chambers all the time that show up.  For us a leaking brake chamber is no problem.  We can fix it in less than 20 mins normally.  But then we do tend to maintain things better than railroads it seems.  Most of my bosses trailers see the shop at least 1 time every 2 months.  Most of our trucks are in the shop every 2-3 weeks for at least a grease job.  If they get written up we fix them.  

 

Okay thanks for that explanation.  But if the process you describe can lead to a leak in the brake chamber, does that not create a brake failure?  Even if the R12 valve senses the leak and adds more air, how does that added air help if it is added to a leaking cylinder or what you call the brake "chamber"?

[Convicted One]

I've got a couple questions, regarding standard procedure.

If you were leaving a cut of say 40 cars on a siding for an as yet undetermined length of time, how many handbrakes are you expected to set? Not all of them right? (at least that is what I thought to be the case)

So, if you are setting only a portion determined by some formula, is there any prescribed method to determine which cars get their brakes set, to fulfill the requirement? 

And, more particular to my curiosity, how does the next person to work with these cars go about determining which brakes must be released?  Do they have to physically test each handbrake, or is there a readily visible indicator of some sort that flags which cars have their handbrakes set?

[Shadow the Cats owner]

If that spring breaks even if the pressure is lost the emergency brake function is lost on that one chamber and it starts to vent the air pressure out the top of the chamber.  It literally fails in a way that causes it to allow safe operation so the drivers can get to a repair shop but alerts them there is a problem to get it fixed.  The leak it creates is less than 2 lbs of air an hour going down the road.  So even the small air compressors we have on the trucks can handle the air loss.  

[tree68]

Convicted One

I've got a couple questions, regarding standard procedure.

If you were leaving a cut of say 40 cars on a siding for an as yet undetermined length of time, how many handbrakes are you expected to set? Not all of them right? (at least that is what I thought to be the case)

So, if you are setting only a portion determined by some formula, is there any prescribed method to determine which cars get their brakes set, to fulfill the requirement? 

And, more particular to my curiosity, how does the next person to work with these cars go about determining which brakes must be released?  Do they have to physically test each handbrake, or is there a readily visible indicator of some sort that flags which cars have their handbrakes set?

It is a formula - start with some specified minumum (it'll be in the rulebook) and then set an additional X% (also in the rulebook).  On top of that, one should do some sort of hold test to ensure that the brakes that have been set will hold, ie, release the automatic and the independent.  If the consist rolls, set more brakes.

You'll be setting the brakes on the downhill side, if there is one.

You might also place a skate or chock if appropriate.

It's not hard to tell which handbrakes are set - shoes hard against the wheel or chains in the rigging being tight are two common indicators.  The cars vary, so it's not just one thing.

Barring special requirements, most folks will set all the brakes in a group (on the downhill side, as noted).  I suppose there could be cases where groups of cars were set out separately, resulting in brakes set throughout the consist.

Unless the cars were left on air, the entire consist needs to be inspected anyhow.

Most situations are repeated on a regular basis, so odds are those who usually work in that area will have a good idea what to look for.

 

[Euclid]

Convicted One

I've got a couple questions, regarding standard procedure.

If you were leaving a cut of say 40 cars on a siding for an as yet undetermined length of time, how many handbrakes are you expected to set? Not all of them right? (at least that is what I thought to be the case)

So, if you are setting only a portion determined by some formula, is there any prescribed method to determine which cars get their brakes set, to fulfill the requirement? 

And, more particular to my curiosity, how does the next person to work with these cars go about determining which brakes must be released?  Do they have to physically test each handbrake, or is there a readily visible indicator of some sort that flags which cars have their handbrakes set?

Another way to test the handbrake securement is to perform a push/pull test with the power of the locomotive.  The need for that is prescribed in the rules depending on conditions of the securement factors.   Such a test was required with the Lac Megantic oil train parked at Nates prior to the runaway. 

The test is to confirm whether there are sufficient handbrakes to hold the train with some extra margin of holding power.  Otherwise if you merely set handbrakes, then release the air brakes, and find the train does not move, you don’t know how close to being able to roll away it is.  If it is just on the edge of being held, it may become free to move due to wind and/or thermal expansion/contraction in the brake rigging of rods and levers. 

Most interesting to me is that the TSB has previously publically stated (in a runaway report in 2011) that a push/pull test is an unreliable indicator of brake holding power on steep mountain grades.  They did not offer a reliable substitute.

In the case of Lac Megantic, the engineer did perform a push/pull test, but did not follow the rules of that procedure.  He performed the test while having the locomotive independent air brakes set.  So his securement was holding during the test but it was relying on a combination of handbrakes and air brakes. 

It was therefore also relying on at least one locomotive left running to keep the air pumped up against any possible leakage.  He broke the rules by including air brakes as a portion of his securement force.  If he had performed the push/pull test for his handbrakes alone, the test would have revealed that the train was not secured.  After he set handbrakes, if he had released the independent brake, that alone would have likely allowed the train to roll.

His actions of securing partly with air brakes (independent application), leaving one locomotive running to pump air assuring maintenance of the air application, and the failure of the securement due to the one engine subsequently being shut down, and the resulting loss of air to maintain the independent application—all of this is a perfect example of why the rules do not allow air brakes to supplement handbrakes for securement.   

I suspect that the rules would allow the setting of the independent brakes and/or the automatic brakes during securement, after the test, but they do not allow testing securement with air brakes being set during the test. 

[Convicted One]

Tree-Euclid:

Thanks to both of you.

Returning a cut of cars to service that has been thusly secured sounds like one of those situations where the whole world is in a hurry and waiting on you? I can just feel the joy.

[Overmod]

If we are looking at a system like Euclid's: the 'parking brake' has to be applied on all cars simultaneously to be worth anything... after which the rules require a pull test without any additional power brake, independent or automatic.  Since this represents a set of 100% of the train brakes it is in excess of any 'optional' formula (like 78% or other alarming figure in the Canadian tables) for holding a train during recharge operations.  Only if it has independent confirmation of application (e.g.visible or 'telemetered' positive engagement) would it be 'safe' not to walk the train to confirm the emergency was engaged on 'sufficient' cars; you would need to reach the rear of the train anyway to confirm adequate set there (to prevent separation and runaway of trailing cars).

As I understand the system he proposes at present, it uses truck spring-brake components to actuate a valve holding pressure in train-brake cylinders acting on the foundation in each car, and presumably to release that pressure upon 'recharge' of the truck-based components.  I presume he has worked out how that is done without illegally compromising the FRA-regulated one-pipe automatic system.  I don't see how he'll avoid walking the train to confirm release when the truck-based system has fully released its special valves, nor what precautions he has made about individual truck-based emergency brakes triggering on moving cars.

I agree with Zug that ECP is a better use of any dollars devoted to automatic system-wide parking brakes.  The adaptive re-use of truck brake components to control a rail-suitable separate brake means, though, is interesting.

[BaltACD]

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure.

[Overmod]

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?

To be fair, I don't think we expect single-man crews to monitor from the cab and trudge down most of the length of a train at the same time ... then reverse the process when it's time to recover the air.

There is also no discussion of the many accidents where some aspect of the handbrake equipment is defective, often without warning even to employees using brakestick leverage.

Personally I think a case can be made for automatic securement (meaning mechanical positive frictional engagement, not any sort of fluid power that can leak off) -- the issue being more one of cost than technical engagement.  Note that something absent from either commercial 'system' of ECP is such a positive brake...

It would be nice to 'mandate' something like 92-day review and testing at next interchange of handbrake function.  I can almost hear the screaming start now, and sometime later, excuses from the sort of people like that CSX crew for which fudging a SPAF was a mere formality, or the Canadians putting equipment into service that had been sitting years without attention...

[Euclid]

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure.

Sure trainmen are expected to set handbrakse, and should be physically able to do so.  But the point is that it cost money, and that money could be saved by investing in a moderinzed system of securement.  The railroad industry frequently invests money to reduce manual labor and its danger. 

[rdamon]

Euclid

 

 

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure.

 

 

 

Sure trainmen are expected to set handbrakse, and should be physically able to do so.  But the point is that it cost money, and that money could be saved by investing in a moderinzed system of securement.  The railroad industry frequently invests money to reduce manual labor and its danger. 

 

The payoff for that investment must be measured in months not years before you will see anything done.

[BaltACD]

Euclid

 

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure. 

Sure trainmen are expected to set handbrakse, and should be physically able to do so.  But the point is that it cost money, and that money could be saved by investing in a moderinzed system of securement.  The railroad industry frequently invests money to reduce manual labor and its danger. 

How much will your device(s) cost - cost to purchase - cost to install - cost to maintain?  $1K per car; $2K per car; $3K per car, $10K per car ?????

What will be installation mandated time? 5 years, 10 years, more?

How will the system's proper operation on the entire train be verified before the crew leaves the train unattended?

[Euclid]

BaltACD

How will the system's proper operation on the entire train be verified before the crew leaves the train unattended?

It will be verified by a push/pull test.

[Euclid]

Overmod

If we are looking at a system like Euclid's: the 'parking brake' has to be applied on all cars simultaneously to be worth anything... after which the rules require a pull test without any additional power brake, independent or automatic.  Since this represents a set of 100% of the train brakes it is in excess of any 'optional' formula (like 78% or other alarming figure in the Canadian tables) for holding a train during recharge operations.  Only if it has independent confirmation of application (e.g.visible or 'telemetered' positive engagement) would it be 'safe' not to walk the train to confirm the emergency was engaged on 'sufficient' cars; you would need to reach the rear of the train anyway to confirm adequate set there (to prevent separation and runaway of trailing cars).

As I understand the system he proposes at present, it uses truck spring-brake components to actuate a valve holding pressure in train-brake cylinders acting on the foundation in each car, and presumably to release that pressure upon 'recharge' of the truck-based components.  I presume he has worked out how that is done without illegally compromising the FRA-regulated one-pipe automatic system.  I don't see how he'll avoid walking the train to confirm release when the truck-based system has fully released its special valves, nor what precautions he has made about individual truck-based emergency brakes triggering on moving cars.

I agree with Zug that ECP is a better use of any dollars devoted to automatic system-wide parking brakes.  The adaptive re-use of truck brake components to control a rail-suitable separate brake means, though, is interesting.

 

The parking brake I describe does apply to all cars in the train simultaneously, or at least a single phase lasting maybe 2-3 minutes. 

What I propose has nothing to do with highway truck vehicle spring brake components.  Nor does it have anything to do with retaining an air charge in the car brake cylinders. 

The lock is applied from the cab by a simple on/off control.  When set, I don’t see why it would be necessary to walk the train to make sure it has set on every car.  The confirmation of sufficient securement would be the push/pull test as is the confirmation today. 

I don’t know that it would be necessary to walk the train after release of the brake lock.  But in any case, it is the actual work of manually setting and releasing of handbrakes that this lock eliminates.  The labor of walking the train is nothing compared to the effort of manual handbrake securement.   

Also, I have never heard of a rule or requirement that bakes be set on the hind end of a train in order to prevent the hind end from running away if it happens to uncouple from the cars ahead of it that have handbrakes set.

Regarding the question of whether money should be spent on full ECP versus spending on this handbrake full train power lock:

I would have to see how this securement function would be accomplished with ECP brakes alone.  It might be that it would be better to combine ECP with the brake lock function I describe.   ECP has native functionality that could be used to simplify the brake lock system I describe.   So I don’t see it as an either/or choice. 

[tree68]

We're in "Pinto" territory here.  Which will cost more - the installation and maintenance of this system on all rail cars, or the continued manual labor?

 

[zugmann]

Euclid

I don’t know that it would be necessary to walk the train after release of the brake lock.  But in any case, it is the actual work of manually setting and releasing of handbrakes that this lock eliminates.  The labor of walking the train is nothing compared to the effort of manual handbrake securement.   

If a few get stuck on, they'll eventually burn off. 

[zugmann]

Euclid

The labor of walking the train is nothing compared to the effort of manual handbrake securement.   

Wow.  By that statement, I know you have done neither. 

Euclid

Also, I have never heard of a rule or requirement that bakes be set on the hind end of a train in order to prevent the hind end from running away if it happens to uncouple from the cars ahead of it that have handbrakes set.

*raises hand*

[BaltACD]

zugmann

 

Euclid

The labor of walking the train is nothing compared to the effort of manual handbrake securement.    

Wow.  By that statement, I know you have done neither.  

Euclid

Also, I have never heard of a rule or requirement that bakes be set on the hind end of a train in order to prevent the hind end from running away if it happens to uncouple from the cars ahead of it that have handbrakes set. 

*raises hand*

Bucky operates in a faireytale world.

[Euclid]

zugmann

 

Euclid

The labor of walking the train is nothing compared to the effort of manual handbrake securement.   

Wow.  By that statement, I know you have done neither. 

 

I am talking about walking 100 car lengths versus walking 100 car lengths and setting a hand brake on each car. 

 

The point is that if a single control securement cab be put into place, it will eliminate the need for manual handbrake application during securement.  That eliminates a huge amount of labor.  So why should that benefit be dimissed just because people still have to do some walking?

[Euclid]

tree68

We're in "Pinto" territory here.  Which will cost more - the installation and maintenance of this system on all rail cars, or the continued manual labor?

 

 

It depends on how many runaway disasters occur because people are too lazy to provide the manual labor.  Accident liability could make the manual labor unafordable.  Accidents could also result in a government mandate. 

[zugmann]

Euclid

I am talking about walking 100 car lengths versus walking 100 car lengths and setting a hand brake on each car. 

You must really hate your relief to do that.

[Euclid]

TSB is focusing on the rise in cases of accidents caused by train brake failure in three different categories:

1. Train securement.

2. Switching cars without using air brakes.

3. Crew losing control of the train movement.

https://www.tsb.gc.ca/eng/surveillance-watchlist/rail/2020/rail-02.html

Note that one of the recommendations for better train securement is the use of physical defenses such as wheel chocks and portable derails:

https://www.tsb.gc.ca/eng/recommandations-recommendations/rail/2014/rec-r1404.html

 

From the TSB link:

“There are physical defenses to protect against the risk of runaway equipment, and these include derails, wheel chocks, mechanical emergency devices, and locomotive auto-start systems to maintain air pressure. New technology is available, such as GPS-equipped devices that can be applied to a hand brake chain, allowing for the remote monitoring of the hand brake status. In addition, some existing technology, such as reset safety controls and sense and braking units, with minor programming changes, can offer additional protection.” 

[Electroliner 1935]

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure.

In a forty below zero (F) wind chill in the dark on the side of a mountain, and over the HOS, and you want a man to set the hand brakes on how many cars. Do you really expect that to be a reasonable request. I would tell you to TAKE THIS JOB ......

[zugmann]

Electroliner 1935

Do you really expect that to be a reasonable request.

In a word?  

 

YES.

[BaltACD]

Electroliner 1935

 

BaltACD

Bucky thinks properly setting handbrakes is too much work.  We do expect people hired for T&E position to work don't we?  Properly setting handbrakes is a segment of the the job they are expected to do.  Setting handbrakes is a matter of public safety, not just railroad procedure. 

In a forty below zero (F) wind chill in the dark on the side of a mountain, and over the HOS, and you want a man to set the hand brakes on how many cars. Do you really expect that to be a reasonable request. I would tell you to TAKE THIS JOB ......

In two words

F'n YES!

At the time before Lac Megantic, the Engineer 'thought' how he secured the train was proper - NOW he knows he shirked his proper duties, he also knows all the lives that were lost are on HIS hands.  Short cuts are fine until you start causing people to die.  Personally, I don't know how the Lac Megantic Engineer can get to sleep at night these years.

The problem is that too many THINK their short cuts are safe - until the the death toll starts and proves beyond any shadow of doubt that they were not.

[MMLDelete]

I read that the engineer screwed up by mistakenly counting the locos' handbrakes as part of the required total.

If the difference between safety and disaster, when securing a trainthat long, of oil tank cars, comes down to three handbrakes, then the railroad's rule was ridiculously inadequate.

Considering what they were dealing with, they should have determined what was surely safe THEN ADDED TEN CARS.

I too wonder how that engineer can sleep at night. But realistically, if he's even semi-normal, he will be tortured by this memory until the day he dies. He effed up spectacularly, but at some level I do feel sorry for him. That's a lot to carry around.

[Overmod]

Lithonia Operator

If the difference between safety and disaster, when securing a trainthat long, of oil tank cars, comes down to three handbrakes, then the railroad's rule was ridiculously inadequate.

Keep in mind that it was Canada's rule before it was the railroad's rule.  And that locomotive orientation describes not using the parking brake as 'securement'.  And that the 'afterthought' number of brakes for the train at Lac Megantic was, as I recall, 76 or so.

The fundamental issue attributable to the railroad at Lac Megantic was the use of the independent brake to hold the train as part of a 'hurry up' asynchronous crew-change procedure.  Together with environmentally-conscious or penny-pinching (take your choice) shutting down of all but the lead unit ... with the lead unit in shaky condition after having been 'worked pretty hard' with recognized problems.

ADDING TEN CARS to what TC told them was 'safe' would have been little additional securement... as things worked out.  Keep in mind that on these cars there is no foundation between trucks, so "one brake" = one truck, something not implicit in the old CROR securement rule and table.

The point about adequate securement 'plus ten cars' on undegassed oil trains at least, stands as proper sense.  Of course we can guess how long it would have taken Harding to make that practical securement on his train.  Or what the dynamic duo in RFC Farnham would have told him had he started...

[Euclid]

TSB is very concerned with the growth of the problem of runaways increasing after we have learned the lessons with Lac Megantic.  If you look at the reference I posted above, they go into great detail. 

In our several discussions on this forum, many have wondered why a portable derail and wheel chocks were not placed to prevent the oil train from running away down the grade from Nantes.  But experts here have repeatedly ridiculed such ideas as being impractical for a host of reasons.

Yet, ironically, the TSB trots out those same portable derail and wheel chock remedies as part of the solution to what they cite as a growing problem with runaways.   

They even propose ideas to assure that locomotives left running to pump air to hold securement do not accidentally stop running.  Both supervisors and the engineer of the runaway oil train at Lac Megantic were fully apprised of the fact that the one engine left running to maintain air pressure holding the train—that engine—had been shut down after the fire.  And yet those three people never bothered to connect the dots.  Unbelievable.

Another thing they propose is hand brakes that can transmit information showing whether or not they are applied.  Now all they would have to do is determine who that information should be sent to. 

The problem with this “belt + suspenders” form of guarantee is that either one can be dismissed because the other one is known to be 100% reliable.   That is precisely what happened at Lac Megantic with the belt and suspenders of hand brakes and air brakes.

In this link, you can see how desperate TSB is.   

From the link:

The situation

Despite significant safety action taken by Transport Canada and the railway industry since the Lac-Mégantic accident (TSB Railway Investigation Report R13D0054) to reduce the number of unplanned/uncontrolled movements of rail equipment, the number of occurrences has continued to trend upwards, posing a significant risk to the rail transportation system.

 

 

https://www.tsb.gc.ca/eng/surveillance-watchlist/rail/2020/rail-02.html