News Wire: Lac-Mégantic disaster trial enters fourth week

Trains Magazine General Discussion
61

This, in blue, is from the fifth conversation in the link I posted above. This is after the discussion between Harding and his supervisors about the fire on the engine and consequent shutdown of the engine due to the fire, and leaving it shut down after the fire was put out. Here, RJ asks the engineer how many handbrakes he applied, and he answered that question:

TH: How the [blank] did that thing start to roll down, RJ?

RJ: I don’t know. How many brakes did you put on?

TH: The units, the V.B., and the first car, seven brakes.

RJ: I don’t know what will happen. The best I can tell you is that Daniel Aubé is on his way there

TH: Okay, well what’s, what you want to do with me, RJ? Don’t leave me out in the cold here.

Here the conversation continues and Harding is assured that the train was secure when it was left after the fire was put out. Also, at this point, Harding has been informed from earlier conversation that the engine had been shut down. Yet even knowing that fact, it does not appear at this point that he has considered that the loss of air pumping might have led t

62

Now excuse me, through this whole thread I have failed to recall exactly what the MMA’s train tie-down rules were. Additionally, as you read the following, I am only examining the engineer’s actions and culpability, not the remainder of the case against the other railroaders, the railroad, and the crude oil companies themselves, who are all also liable in part for this disaster - no disaster ever has a single cause.

The long and short of it is this: if the engineer did NOT follow the printed rules for tying down his train, then he is at least partially at-fault for this disaster. It’s ethics 101, and it’s printed in every railroad rulebook I’ve ever read: these rules supercede anything anybody tells you, and when in doubt, the safe course must be taken. There is room for good-faith challenging, at least in the US, but I’m not sure if Canada has a similar rule. Perhaps somebody can fill us in on that count.

Given that, here is a small sampling of these safety clauses from active or slightly-out-of-date rulebooks. They’re all literally the first rules in the book - that is how important safety is! The breaking these rules is inexcusable!

From CN’s US Operating Rules, 8th Edition (currently in use)

Rule A: Safety. Safety and a commitment to obey the rules are the most important elements in performing duties. If in doubt, the safe course must be taken.

Rule 100: Employees must be familiar with and obey all rules, regulations, and instructions. […bunch of stuff about training…] …They must properly report any violations to the proper supervisor. Employees must ask their supervisor for an explaination of any rule, regulation or instruction of which they are unsure.

Or, from CSX’s Operating Rules & Signal Aspects and Indications, Jan 2010 (since superceded but unlikely to have amended these sections!)<

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Key trains, yes always. Other non-Key trains with Hazmat, maybe. If certain conditions are met, a walking inspection is not required. Fortunately, the times that trip I lost the air we fulfilled the conditions.

Jeff

64

Here is the accident report and the section on the handbrake rules begins near the top of the document with this:

1.12 Rules and instructions on securing equipment

http://www.tsb.gc.ca/eng/rapports-reports/rail/2013/r13d0054/r13d0054.asp

My understanding is that the engineer failed to comply with the rules and/or the special instructions of MM&A. There may be that conclusion stated in the report somewhere without the need to go through the rules.

We know that the engineer failed to perform a proper effectiveness test because he performed it with the independent brakes set.

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It is specifically to be noted in the report, both in the discussion and in the quoted MM&A rule, that railroad policy clearly states no air is to be applied when a pull test is made. It is difficult for me to comprehend how any ‘failure of training’ could leave an engineer able to conclude that a pull test with independent air applied, with or without the piddling contribution due to the QRB valve red herring, could satisfy this rule.

Something I still haven’t seen is the ‘necessary’ change to the number of applied brakes when the train is left standing on a grade. It is obvious, only partly in retrospect, that a rule giving adequate standing resistance to a consist on the level would be grossly inadequate to purpose on a 2% grade, and this is clearly shown in both the CP and CN instructions; it is strange to me that no mention of this is seen in the quoted parts of the MM&A rules.

66

Thanks for the link to that document. First off, it confirms that the rules in effect were CROR, which is a time-tested rulebook which contains the same clauses as I previously mentioned about the safe course of action and the supremacy of the written rule over anything else.

It also confirms that indeed, the engineer broke the rules when tying down the train.

It is usually di

67

Guys, we’re starting to drift off a very important aspect of the topic. This thread is not about who was or wasn’t likely to blame for the Lac Megantic accident; that horse was pretty well beaten years ago, when we first took up and discussed the accident report and some of the other findings.

This thread is about the trial of the engineer and the culpable RTC personnel, and what is (and isn’t) brought up or established during the course of those proceedings. Euclid’s original questions specifically referred to this (he was considering things that he wanted to see specifically addressed to the engineer in cross, and answered specifically by him. All we’re doing by revisiting the language in the TSB report is looking carefully at what he ‘should’ be asked, even to clarify the situation, during the trial.

I have not quite established whether this trial is being ‘geared’ somewhat toward facilitating aspects of subsequent civil suits, but considering the bankruptcy of MM&A the previous emphasis on ‘blame the big bad American management for all the problems’ might not help the Canadian victims much if at all.

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Here is the elaboration from the accident report covering details in depth including the number of handbrakes required and and number of handbrakes set by the engineer:

2.3.1 Number of hand brakes

As demonstrated in this accident, railway rules related to the securement of trains are important because of the potential consequences of improperly secured equipment.

MMA followed Canadian Rail Operating Rule (CROR)112, which stated that a “sufficient” number of hand brakes must be applied and an effectiveness test must be performed to verify that the retarding force is adequate. In addition, MMA had supplementary rules in its General Special Instructions and Safety Rules. These rules reference a chart detailing the minimum number of hand brakes to be applied—the “10% + 2” instruction. Since all air brake systems leak, MMA’s instructions also explicitly stated that air brakes “must not be depended upon to prevent an undesired movement.”Footnote 133

Furthermore, the chart detailing the minimum number of hand brakes was only meant to be a guideline and, as stated in the Safety Rules, “additional hand brakes may be required” because of factors such as grade, the number of cars, the weight of a train, and weather conditions.

In addi

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When in a hole - Stop Digging!

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He does not have enough “street smarts” to stop.

71

In the fifth conversation partly quoted on at the top of this page, the main concern of Harding and R.J. seems to be the fact that the engine caught fire. Now that they know that the train ran away, R.J. asks Harding how many handbrakes he set. Harding said he set seven, and note that he makes no mention of also setting the independent. Neither person seems to feel that seven handbrakes was inadequate.

This series of audio/text transcripts also includes the point where Harding was told by R.J. that it was the oil train that rolled down and set the town on fire. Prior to that, Harding had seen that the a big fire had broken out in Lac Megantic, but he did not know what caused it. Harding called R.J. and told him about the fire. Harding thought it might be a broken gas line, and his concern was that much MM&A rolling stock had been burned up in the yard which was included in the fire.

At that point, R.J. seems to question whether it could be the oil train that Harding left at Nantes that rolled down and started the fire. However, Harding assures R.J. that the oil train was secure at Nantes. Harding was convinced that the fire had nothing to do with the oil train.

Then in a subsequent conversation, while Harding was still speculating on the cause of the fire, R.J. carefully informed Harding that it was his (Harding’s) train that rolled down and caught fire. Harding’s reaction is profound astonishment. R.J. confirmed that he had factual information that it was the oil train that was burning in Lac Megantic.

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Well my take is that is plenty of blame to go around and even the regulatory agencies are included. If you read the whole story, they talk about the risk management, the safety management system, etc. The locomotive had been improperly maintained (bad repair on the cam with some improper material (bondo) the locomotives braking system (“Because the quick release brake (QRB) valve on MMA 5026 was defective”) had a flaw, the track was defective, (worn down to where flanges could impact splice bars). The shippers didn’t rate the cargo properly, etc. It seems the TC and other agencies didn’t enforce the rules in any meaningful way. The MMA had a very lax safety culture. Their trainging & testing was deficient. And as always, when there is no checks and balances, things come together to cause an accident fhat kills 47 people.

Now they are trying the engineer who failed to properly secure a defective train on a track that was defective and with no one to help him in the dark of night after being on duty until the hours of service caught up with him. As the expression goes, “IT’S A HELL OF A WAY TO RUN A RAILROAD!” It sure looks to me that he is being made the goat, and yes he did fail to properly secure his train, but the deck was stacked against him. I have sympathy for him sent out to do a job with bad training, bad testing, bad equipment, bad culture, and no support. And now he has to take the fall.

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This trial is about whether the blame lies with the last person who failed to perform his duty or with a larger company culture failed to perform several duties that contributed to the ultimate failure of the last person. I do not know how this can logically be decided. There are very persuasive arguments on both sides.

There are a lot of detailed instructions on how to properly secure trains, including advising that trains should be left secured in the least dangerous locations possible. The instructions are in layers of stipulations and conditions that must be evaluated in order to reach a proper conclusion.

Generally, there are two parts to the instructions:

  1. The tables and information that recommends the number of handbrakes to be applied.

  2. The practical handbrake effectiveness test made by pushing and pulling on the train with the locomotive to see if the number of handbrakes applied is adequate.

It is part #2 that counts, so part #1 is not even necessary except to make the process a bit less labor intensive. Part #1 is just a guide to get into the ballpark of the correct number of handbrakes to set before stopping to test. Yet with its complex details, part #1 might easily be interpreted in carrying a lot of weight. A person might consider part #1 to carry so much weight that he perceives that part #2 is merely a confirmation of what should true about Part #1. This leads to the belief that

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The MM&A rule does not forbid automatic air only; it forbids any use of air.

The Canadian rule forbade the use of automatic ON a secured train, whether in addition to handbrake securement or not. MM&A did have the practice of leaving the automatic released so the single-man would not have to do the required brake test after 4 hours application, but (1) law would not allow it to be used to hold the train anyway … but note independent application wasn’t forbidden … and (2) it was assumed by rule that the train would be pull-tested without air to be secure.

Harding had long experience on a railroad with explanation of the need to increase ‘number of handbrakes’ on grades (that was mentioned in the TSB report in a different context). To say he was somehow ignorant because of ‘faulty company training’ is patently ridiculous; to say he took the easy way out of securement by following only the simplest rules guideline is … well, the sort of thing I hope they evoke properly in context in the trial testimony.

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I am not sure I understand what you are saying. These two comments from your above post seem to be in conflict.

Also, I did not know that Canadian rules forbade the use of automatic on a secured train. I had understood they only forbade using automatic to take the place of handbrakes required for 100% securement by handbrakes. I thought Canadian rules allowed option of setting the automatic for backup protection after the train was secured by handbrakes. And now I understand that since the Lac Megantic wreck, the Canadian rules require the setting of the automatic brakes as backup protection—the so-called Ten-Second-Procedure.

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You have mangled my quote: it’s the Canadian rule forbidding automatic application that did not include independent, not MM&A’s which disallowed any use of air for securement.

I believe the Canadian prohibition of automatic brake was discussed again in one of the pathetically few trial-coverage stories or discussion thereof.

I recall at the time thinking this was a bit like the 1937 prohibition on new four-wire switches — because folks who might ‘forget’ three-wire was legal might assume a fixture was de-energized as if on four-wire when it wouldn’t be. It was as if Canadian authorities ‘knew’ crews would get sloppy with full handbrake application and pull-test securement if they “could” set the automatic to cover … so setting the automatic was forbidden. Unsurprisingly they have crawfished and made it SOP to recommend that ‘ten-second procedure’ all the time … now that the train is down the hill.

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I don’t know about the U.S. or other jurisdictions, but there is no such rule in Canada. On CN trains are routinely parked for far longer than that (sometimes for several days) with a full service application of the automatic brake, and all the new crew has to do is release it and start pulling, after the Conductor releases the handbrakes of course. No air test, the only requirement is for the tail end pressure to reach 75 PSI and the flow to drop below 60 CFM.

The only requirement for an air test en-route is if equipment has been left off air for more than 24 hours, then a No. 1A brake test is to be performed by the train crew. This consists of the Conductor walking the train and verifying that all the brake pistons apply and release properly.

And as I noted in an earlier post, before Lac-Megantic we would leave trains unattended with a full service application of the automatic, full application of the independent and only one handbrake on the lead locomotive. Legal at the time, not anymore.

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The current train securement rule, from the CROR. Note how it differentiates between on air or off air (Locomotive attached or unattached), and between yards and main track, sidings & high risk locations:

112. Leaving Equipment Unattended

In the application of this rule:

  • (i) Equipment is considered unattended when an employee is not in close enough proximity to take effective action to stop the unintentional moving of equipment.

  • (ii) Physical securement or mechanical devices are:

    • hand brakes;

    • air brakes;

    • derails;

    • mechanical emergency devices;

    • locomotive equipped with a reset safety control (RSC) with roll-away protection where air pressure is maintained by continuous operation or auto start is provided;

    • bowled terrain; and

    • if in a yard: retarder, stop-block, wheel chocks and skates.

  • (iii) High risk locations, as determined by a risk assessment, must be identified in company instructions.

  • (a) When equipment, including a locomotive without an air source, is left unattended on a main track, subdivision track, siding or high risk location, at least the minimum number of hand brakes as indicated in the hand brake chart in (k) must be applied and determined to be sufficient through an effectiveness test described in (e), and at least one additional physical securement or mechanical device must be used. When air brakes are used as an additional means of physical secur

79

According to your more recent comment, I assume that here you mean forbids any use of air during securement that is intended to prevent undesired movement.

As I understand it, many railroads allowed the use of air brakes during securement as long as it was not intended to prevent undesired movement.

The MM&A had a rule that prohibited the automatic brake from being applied during securement even if it was not intended to prevent undesired movment. I assume that it was okay on the MM&A to leave the independent brakes applied during securement as long as it was not intended to prevent undesired movement.

Therefore: On all railroads, no air brakes at all to be applied with the intention of preventing undesired movement.

On all railroads except MM&A, automatic and independent air brakes allowed to be applied during securement as long as it is without any intention of preventing undesired movement.

On MM&A, independent air brakes allowed to be applied during securement as long as it is without any intention of preventing undesired movement.

On MM&A automatic air brakes not allowed to be applied during securement for any reason.

This is why I made the distinction a few posts up about the difference in the way MM&A rules apply to the automatic and independent applications during securement.

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[quote user=“SD70M-2Dude”]

Euclid

And now I understand that since the Lac Megantic wreck, the Canadian rules require the setting of the automatic brakes as backup protection—the so-called Ten-Second-Procedure.

The current train securement rule, from the CROR. Note how it differentiates between on air or off air (Locomotive attached or unattached), and between yards and main track, sidings & high risk locations:

112. Leaving Equipment Unattended

In the application of this rule:

  • (i) Equipment is considered unattended when an employee is not in close enough proximity to take effective action to stop the unintentional moving of equipment.

  • (ii) Physical securement or mechanical devices are:

    • hand brakes;

    • air brakes;

    • derails;

    • mechanical emergency devices;

    • locomotive equipped with a reset safety control (RSC) with roll-away protection where air pressure is maintained by continuous operation or auto start is provided;

    • bowled terrain; and

    • if in a yard: retarder, stop-block, wheel chocks and skates.

  • (iii) High risk locations, as determined by a risk assessment, must be identified in company instructions.

  • (a) When equipment, including a locomotive without an air source, is left unattended on a main track, subdivision track, siding or high risk location, at least the minimum number of hand brakes as indicated in the hand brake chart in (k) must be applied and determined to be sufficient through an effectiveness test described in