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.
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.
EuclidMy 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.
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.
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.
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.
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.
If GM "killed the electric car", what am I doing standing next to an EV-1, a half a block from the WSOR tracks?
Paul MilenkovicAgain, 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.
It's been fun. But it isn't much fun anymore. Signing off for now.
The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any
Paul MilenkovicThe setting of blame is not the point.
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.
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).
A list of measures to be considered is, yes, "degassing" the crude prior to shipment to make it less flammable,
[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; ...
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.
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 [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?
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.
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).
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.
EuclidA 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, 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.
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.
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 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.
The same defective duo who kept Harding from coming back up to take care of his train when he found out there was trouble.
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.
EuclidSo that means the firemen are responsible for the disaster?
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.
"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.
They were but one of the holes in the Swiss cheese that lined up for that incident.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
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.
Euclid So that means the firemen are responsible for the disaster?
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.
Never too old to have a happy childhood!
BaltACDThere was only ONE man who could have stopped the Swiss Cheese Holes from ever getthing the opportunity to line up.
Yep.
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.
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.
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.
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?
BaltACDHis 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.
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 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.
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.
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...
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.
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.
Lithonia OperatorI 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?
BaltACDHave 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.)
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.
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.
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.
EuclidSo 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.
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.
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.
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.
Um, does anyone remember the RBMN Tamaqua derailment?
Anyone know what caused it? I think we know enough about Lac-Megantic by now.
Flintlock76 I think we know enough about Lac-Megantic by now.
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......
Greetings from Alberta
-an Articulate Malcontent
SD70DudeBut 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.
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 But we don't know who to fine, who to jail, and who to hang. Isn't that what really matters?
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.
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.
Lithonia Operator Meanwhile back at the ranch, does anyone know if RBMN cleaned up their derailment?
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.
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