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.
Lithonia OperatorThen 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.
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
EuclidI 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?
EuclidThe 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.
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.
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.
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.
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.
Never too old to have a happy childhood!
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.”
tree68 .... Who knows - all it might have taken was the handbrake on one more car. (That's rhetorical - no need to dissect it.)
Thanks to Chris / CopCarSS for my avatar.
EuclidHow 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
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.)
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...
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 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?
EuclidIn 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.
Root causes and contributing factors.
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.
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?
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.
Paul MilenkovicIf 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?
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.
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?
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.
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?
If GM "killed the electric car", what am I doing standing next to an EV-1, a half a block from the WSOR tracks?
tree68As I recall, he included the locomotives in the number of brakes he set.
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.
Flintlock76 "The holes in the Swiss cheese line up." Brilliant! And it explains so much in so few words. I'll remember that one.
"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.
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?
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.
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.
Lithonia OperatorDid 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).
Paul MilenkovicThe 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?
The aviation people who discuss their accidents over at Professional Pilots' Rumor Network have an expression "The holes in the Swiss cheese lined up."
Euclid That is the sole cause of the runnaway.
I would use "primary" instead of sole. There were a lot of contriubuting factors.
Lithonia OperatorMan, 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.
BaltACDEd Ellis was not in charge of the MM&A for the Lac Megantic incident, Edward Burkhardt was.
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