posted
The Canadian Safety Board has now released their report of their investigation into the July 6 2013 incident at Lac Megantic. I have posted this head's up here, but discussion should move forth at the Canadian Forum.
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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(oh well, so much for discussing this topic at the Canadian Forum)
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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posted
I'm curious whether leaving trains standing at the top of that grade unattended overnight was standard practice? It appears so and that....well..... it just seems that perhaps that is something that might have needed to be questioned sooner.
-------------------- David Pressley
Advocating for passenger trains since 1973!
Climbing toward 5,000 posts like the Southwest Chief ascending Raton Pass. Cautiously, not nearly as fast as in the old days, and hoping to avoid premature reroutes. Posts: 4203 | From: Western North Carolina | Registered: Feb 2004
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quote:Originally posted by notelvis: I'm curious whether leaving trains standing at the top of that grade unattended overnight was standard practice? It appears so and that....well..... it just seems that perhaps that is something that might have needed to be questioned sooner.
Not only that but with the engine running, the door unlocked, and the keys in the ignition, as it were. And next to a main road. SOP at the time.
-------------------- Geoff M. Posts: 2426 | From: Apple Valley, CA | Registered: Sep 2000
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posted
I have now had the opportunity to give this thorough report the attention it deserves, and I can only conclude that this was the incident waiting to happen.
All told, there appears to be a management that wanted to cut every corner there was to cut, and 'brownie points' were passed out to those managers who could find more such corners.
What was not knowledge to the various news sources covering the incident was that the Locomotive Engineer (LE in the Report), Mr. Harding, was that there was time at Nantes to secure the train in accordance with the applicable Special Instructions. Those instructions call for securing a train being left unattended with 'ten percent plus two' units being secured with handbrakes. In this case, nine such units (locos and/or cars) needed to be secured; only seven were done so. The Report states the train departed Farnham at 130P and arrived at Nantes 1050P. Since the "clock started ticking" at about 1P allowing for "prep" time, there was still more than one hour available to handle the train. But time represents pay, and also represents that the ten hour "rest clock" won't begin until the LE was "tied up" at a hotel.
The LE knew that "there was trouble" with the leading unit that was to be used to supply air to the brake lines that was the primary source of train securing. He reported such to two Train Dispatchers (RTC or whatever is the twenty first century term), they both said "forget it'. Even the driver of the taxicab called to transport the LE to a hotel, sensed something was wrong.
Well something was wrong to which the Nantes Fire Department responded. In the picture of things it was a minor fire and that FD had been trained to shut off any engine in the vicinity of a fire. There was a railroad employee at the scene - a Track Dept. employee, and the RTC was aware of the situation (the RTC was also certified as an LE). But the one employee, the LE, in the proximity of the fire incident was slumbering away in a nearby hotel.
Why wasn't the LE recalled to the scene under emergency conditions and ensure that another locomotive was operating and providing air to the unattended train?
Well volks, that would have cost some 'Loonies" (CD$) as he would be under pay (likely 8hrs minimum) and his ten hour rest clock would start again only when released from the emergency call.
The "rest of the story" is too tragic and otherwise documented to bear repeating here.
Criminal prosecution is to move forth from this incident and it would be inappropriate at this page to speculate whether or not a conviction will arise. But something tells me the wrong people will be prosecuted - the people that should be prosecuted all wear White Collars.
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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posted
I've read the report several times trying to understand the technicalities of the brake systems and to look for underlying issues like fatigue (human or mechanical) that may have contributed to the disaster. It seems that a startling number of small failures, combined with some poor judgement, created this catastrophe.
The biggest operational error seems to be the decision to keep the malfunctioning locomotive operating while 4 other working locos were shut down. Would there have been a problem maintaining the air system from one of the other locomotives? If not, then the decision to keep the bad loco running was truly stupid.
Also, is it smart to carry hazardous material with a 1 person crew? By railroad standards, a 10 hour day isn't long, but 10 hours alone in a locomotive might be considerably more fatiguing (and boring) than 10 hours spent with another person. Given that the failure to set an adequate number of hand brakes was a critical failure in this event, I have to wonder if another person on the crew would have ensured that the required number of hand brakes were set. I think a 2 person crew would have been more alert and aware of the potential hazards present at tie-up: hazardous cargo, the malfunctioning locomotive, the grade (is less than 1% really recognizable?).
Would a train consist normally lose its air after aproximately 1 hour without power? If that's normal, then the failure to set enough hand brakes seems worse.
The bottom line in this tragedy is that everyday an incredible amount of potentially dangerous cargo is being transported by shortlines similar to the MM&A. I don't think that this tragedy would have occurred on BNSF or UP mainlines, (at least not for the reasons that it happened on the MM&A), but not all of the oil is carried on Class I tracks. And that is a huge problem.
Posts: 831 | From: Seattle | Registered: Jan 2011
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Regarding Mr.Vincent's immediate thought, we should await the NTSB report with regard to Cassleton. Here we have a "UN 1267" incident occurring on the BNSF-likely the best managed railroad in the world. No corners get cut on Warren's 1:1 Lionel set.
All told, there has been quite a learning curve for the entire community involved in the handling of Bakken crude, but Warren will ensure his pupils stay awake in class.
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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posted
The preliminary report from Casselton is available. Reading between the lines, it looks like there was a broken axle (on the grain train?), a derailment, a collision and an explosion. Crew error doesn't seem to be a cause--but, we'll see.
Posts: 831 | From: Seattle | Registered: Jan 2011
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posted
I've been trying to get my head around this for a while but I can't understand why a source is required to APPLY the brakes on this particular train. Normally the safe default is that something is required to RELEASE the brakes - i.e. air pressure in the line, and if you remove that something then the brakes apply. So what am I missing here?
-------------------- Geoff M. Posts: 2426 | From: Apple Valley, CA | Registered: Sep 2000
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posted
Geoff, there are two sets of brakes, no? A string of "live" cars operates like you say, but a string of "parked" cars depends on mechanical brakes that need to be manually set once disconnected from air.
Think your car's foot brakes vs. emergency brakes.
Posts: 1530 | From: Ocala, FL | Registered: Dec 2006
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quote:Originally posted by Ocala Mike: Geoff, there are two sets of brakes, no? A string of "live" cars operates like you say, but a string of "parked" cars depends on mechanical brakes that need to be manually set once disconnected from air.
Think your car's foot brakes vs. emergency brakes.
Two sets, yes. One set should always operate in a fail safe manner though. Remove the air supply and the brakes should apply - whether because a moving train has separated, or because the engine supplying air has been shut down.
It's more like the luggage trolleys you get at some airports - you have to squeeze the handle to release the brakes. Let go of the cart and the brakes apply.
-------------------- Geoff M. Posts: 2426 | From: Apple Valley, CA | Registered: Sep 2000
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posted
Geoff, maintaining brakes on a car when set by the air system requires continued air under pressure in the air reservoir on that car. If it "bleeds off", that is loses its charge, the brakes release. That is why setting of hand brakes is essential for any car that will bbe left standing.
My civil engineer brain says that the first and most important mistake was the choice of parking spot. Leaving a train standing where it can roll away by gravity is ALWAYH a bad idea. the best safety device of all for keeping a train or any vehicle where you leave it is gravity. There should have been an upgrade, even if a very slight one away from the train's standing position in both directions.
Posts: 2810 | From: Olive Branch MS | Registered: Nov 2002
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posted
Wouldn't it be difficult (impossible?) to operate hump yards if no air meant that the brakes were locked on a car? On Amtrak, I know that the first sound I hear when a train goes into emergency braking is the release of air from the brake lines.
I have to wonder if a less than 1% grade is even noticeable to an engineer. The timetable might list the grade, but at 1130pm, I don't think very many people would notice that the train was parked on a grade. But that doesn't mean that the hand brakes shouldn't be set.
Posts: 831 | From: Seattle | Registered: Jan 2011
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quote:Originally posted by George Harris: Geoff, maintaining brakes on a car when set by the air system requires continued air under pressure in the air reservoir on that car. If it "bleeds off", that is loses its charge, the brakes release. That is why setting of hand brakes is essential for any car that will bbe left standing.
But that's not failsafe, and this is what I'm trying to get at. The single point of failure failed. I'm not ignoring the whole bunch of other factors involved. As Vincent says, hump yards are the only explanation I can think where the default of "runaway mode" would be useful - but at what cost?
-------------------- Geoff M. Posts: 2426 | From: Apple Valley, CA | Registered: Sep 2000
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posted
Here is a transcript as circulated by the Toronto Globe And Mail of telephone conversations between the LE (Harding) and the Train Dispatcher (RTC).
I don't know what in heaven's name it took on that "toonerville trolley' excuse for a railroad for first line employees to realize they had an emergency on their hands as soon as the "Pompiers du feu" were called to the scene. The RTC was a qualified Locomotive Engineer, should have known that the Fire Dept was trained to shut off a locomotive, but not in train handling.
It is so simple; LE Harding should have been recalled to the scene under emergency conditions. True, he would have been under pay and his Rest broken, but 'it's all bets off' under HOS in an emergency.
Whoever created the penny pinching culture prevalent in that outfit is the party who holds the blame for the incident occurring - that is who should be a criminal defendant in any such proceedings.
But alas, there are underlings to serve up as sacrificial lambs.
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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quote:Originally posted by Vincent206: I have to wonder if a less than 1% grade is even noticeable to an engineer. The timetable might list the grade, but at 1130pm, I don't think very many people would notice that the train was parked on a grade.
Yes, and yes.
Posts: 2810 | From: Olive Branch MS | Registered: Nov 2002
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All the individuals charged by the transportation ministry worked for the train’s operator, Montreal, Maine & Atlantic Railway Ltd., or MM&A, which is now defunct. They include the train’s driver, Thomas Harding, and Jean Demaître, a train operations manager. The two men separately pleaded not guilty last year to criminal charges filed by Quebec prosecutors in connection with the accident.
Looks like the Mounties nailed the CEO of the Canadian subsidiary MM&AC, but only at such time I learn that Eddie UNOHOO is escorted off the plane by US Marshals and handed to the RCMP, I'll say "the Mounties got their man".
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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Canadian Newssources report that all former MM&AC employees criminally charged arising from the incident now almost five years ago, have either had the charges withdrawn or have been acquitted at trial:
After nine days of deliberations, jurors have acquitted the three former Montreal, Maine and Atlantic (MMA) railway employees charged with criminal negligence causing death in the 2013 Lac-Mégantic rail disaster.
There was an audible gasp in the courtroom and family members of one of the accused cried when the verdict was delivered early Friday afternoon at the Sherbrooke, Que., courthouse.
Locomotive engineer Tom Harding, 56, rail traffic controller Richard Labrie, 59, and operations manager Jean Demaître, 53, were all charged after the derailment of a runaway fuel train early on July 6, 2013. Several tankers, carrying highly volatile crude oil exploded, turning downtown Lac-Mégantic into an inferno and killing 47 people.
Through tears, Labrie described his relief. He said his thoughts were always with and continue to be with the community of Lac-Mégantic.
"I would like to say the people of Lac-Mégantic, what they went through, they showed a huge amount of courage," he said
So far as the "pawns" go, justice has been served, but justice for all injured parties remains unserved until one certain individual noted immediately is incarcerated in whatever Canada has for a "supermax" and never sees the light of day again (Canada does not have a death penalty).
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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The seasoned rail investor takes issue with Canadian government findings that the railroad lacked a safety culture and laid blame squarely on Thomas Harding, the MM&A engineer who failed to apply an adequate number of handbrakes on the train before leaving it unattended.
"I always thought that safety was one of the priorities as a rail manager," Burkhardt tells Trains. "Whatever you do, we proved that it wasn't sufficient. It just means doubling down and learning from mistakes
Posts: 9979 | From: Clarendon Hills, IL USA (BNSF Chicago Sub MP 18.71) | Registered: Apr 2002
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