No way to run a railroad.
“There were missteps and miscommunications, procedures not followed and poor decisions,” NTSB Chairman Deborah A.P. Hersman said at the hearing in Washington, D.C. “There were multiple points where this catastrophe could have been averted but it was not.”
Putting aside the lost of innocent bystanders’ lives, the CN apparently doesn’t look after its train crews very well either. I wonder what, if any reaction there would be, if any of the crew had been killed in a derailment that should not have occurred.
Reaction from the public if the train crew alone had been killed or reaction from other railroaders if the train crew were the only fatalities?
Or are you wondering if there would have been as much negative press if only the crew dies?
I would suggest that the only reason it made headlines this late is because of the civilian fatalities.
If the crew had died, and been the only ones, then it would just be a few more numbers in the annual FRA report.
I can feel empathy for the survivors, all they were doing was waiting for a train to pass, simply in the right place at the wrong time.
Hope they collect every single dime.
One can’t reasonably draw sweeping conclusions from a single incident, however tragic. CN apparently acknowledges fault and wrong doing, but I don’t think this terrible accident is indicative of a “we don’t care” attitude" at CN. Surely they’ve changed their procedures and have fired those who are responsible. CN isn’t the only railorad to have had an accident, and almost all accidents are due to someone’s error or oversight at some point. Obviously this is tragic for those who were killed, and their families are entitled to every last dime of that 36 million.
For the railroad to have known for the washout for an hour without warning the train, it seems like quite the candy-coated explanation to say that, “There were missteps and miscommunications, procedures not followed and poor decisions.” Do they think the public is that stupid?
I may have not stated what I meant clearly. Putting aside the bystanders, it seems that a railroad has a real problem when it has information that affects the safety of its trains and crews but has a system that doesn’t reliably inform them of the danger, even with ONE hour to do so. It isn’t like it was a matter of seconds or minutes or that radio or cellphone technology wasn’t available. Kate Shelly managed 130 years ago to run in the dark to stop a CNW train from disaster with a damaged bridge and help rescue a crew. I would think CN (IC) employees, in the US at least, should have concerns.
You hear about incompetence everywhere…CN certainly does not have the monopoly on that. They draw from the same labor pool everyone else does, so they too get their share of bad apples. However one case doesn’t necessarily point to a system wide problem nor does it suggest that nobody at CN cares and that they willfully put their train crews in danger. Clearly someone didn’t do his/her job…mistakes will happen as long as people remain imperfect. The safety board’s conclusions were obviously right on the money…failure to inform the train crew of the impending danger would most certainly be a “mis communication”…or more precisely, a non communication…and you’d have to believe that unless you’ve got evidence that someone intentionally did not advise the crew.
I would like to see the report itself, not just the quotes in the newspaper. What I would like to know is whether the call went to Homewood, IL or to Montreal, PQ. If it went to Montreal I can better understand a degree of delay. Nevertheless if CN went to centralized notification they should have had a better system for disseminating the information to their people who could do something with it. Several other Class Is had similar incidents when they went to Centralized Emergency call-in systems, though I am not sure if any others involved fatalities.
Centralization.
Fewer people doing more. But when is fewer “not enough” and more “too much”?
According to the article, the NTSB has said:
“There were missteps and miscommunications, procedures not followed and poor decisions.”
That sounds a lot more like a system failure than one person making a mistake.
Not necessarily…one person can do all three…happens all the time but fortunately not with such devastating consequences.
Great quote ! [tup] Send it to Scott Adams for a Dilbert strip ? But be careful - somebody might try to make you a management consultant or something . . . [:-,]
- Paul North.
NTSB Press Release “Track Washout Caused 2009 Train Derailment in Illinois” dated February 14, 2012: http://www.ntsb.gov/news/2012/120214.html
Note this excerpt from it: "A synopsis of the NTSB report, including the probable cause, conclusions, and a complete list of all the safety recommendations, is available at: http://www.ntsb.gov/news/events/2012/cherry_valley/index.html.
The NTSB’s full report will be available on the website in several weeks."
If you go to that latter link. it looks like a pretty comprehensive report even now:
Railroad Accident Report - Derailment of CN Freight Train U70691-18 With Subsequent Hazardous Materials Release and Fire
Cherry Valley, Illinois
June 19, 2009
NTSB Number: RAR-12-01
- Paul North.
Thanks for posting that link Paul,
After reading it, the cause indeed sounds like a systemic problem with CN, as opposed to a mistake by one person. After all, the remedies recommended by the NTSB are all about new systems and programs. It says nothing about one person making a mistake.
All the report says about the possible prevention of this derailment by notifying the crew is that the police emergency communication system was inadequate. Not only does that sound systemic, but also it makes me wonder what it even means. Did somebody leave some wires unconnected?
It’s almost impossible to get it exactly right. The minute you hire enough hands to take care of increasing sales, sales drop and you’ve got people sitting around and under employed. Conversely, the minute you adjust your workforce in response to flagging sales, things pickup and you’re caught without enough people to do the work. I’ve never had it balanced exactly right for more than a few minutes. I’m also shorthanded or have too many people available for the work available.
No markings at the crossing yet. The people handl
I agree that the tank car design was certainly relevant to the consequences of the derailment, but my point is about how much detail the report offers about tank car design and every other conceivable minutia, while glossing over the failure of the emergency system that would have prevented the wreck.
To be consistent, considering the way they dismiss the failure of the emergency system, I would not expect any details about the mechanics of tank cars.
Perhaps unbiased objectivity is not to be expected from the NTSB.
Wait for the final report.
I will say that it is easier for the NTSB to point to specifics about the Tank Car design, rather than trying to describe an ideal phone/Internet/Data system to alert the correct Dispatcher and provide the necessary location and details. The lack of Crossing markings would make it more difficult to identify the correct area, as the Dispatcher might or might not be familiar with the highway crossings.
I understand that somebody reported the washout to the railroad police. All I want to know is what they did about it.
First point understood and taken.
As to the rest - OK, but in the meantime: Why can’t the NTSB use the systems, procedures, and markers of other similar-sized Class I’s as “best practices” in the industry that should be implemented and emulated, at least until a better system is thought up and rolled-out ? The plaintiffs’ lawyers will certainly try to do that, to establish a “standard of care” in the industry that could have and should have been followed, and which likely would have prevented the tragedy.
Are the NTSB and the unenlightened members of the industry to remain stupefied into inaction by “the perfect is the enemy of the good” syndrome once again ?
- Paul North.