NTSB: Canadian National failed to warn train before derailment

In recent years CN has issued RULE W warnings (severe weather) to trains along its subdivisions.

Partial Quote:

Flash Flood Warnings– At locations specified by the RTC, timetable or
Operating Bulletin, trains will operate prepared to stop short of obstructions.

I believe they have been working hard to get these warnings out and have trains slow down.

Historically the biggest problem in communications between railroads and outside parties is determining where HERE is.

In it’s simplest form - Railroads are defined by milepost. The rest of the world is defined by hundred block or where the Jiffy-mart is. Two different languages.

The carriers efforts in placing DOT crossing identification plates at each crossing has had a beneficial impact in bridging the gulf between these two languages, however, in many cases there is still a lot of territory where confusion can reign - when trying to identify a location that is not in the immediate vicinity of a road crossing that has DOT identity plates. A second area of confusion is where multiple carriers are operating parallel to each other through a location - the outside party may only notify one carrier and that may not be the correct carrier (carriers have become more knowledgeable about this and in addition to notifying the party to contact the other carrier(s) will also contact the other carrier(s)) - Notification of the additional carrier(s) takes time - and in many cases time may be a priority.

Anecdote from reality - Carrier was notified by Outside Party of a truck being ‘hung up’ on a crossing (not specified) in a named city area. The named city area was notified by the carrier of what the OP reported, in the interim the carrier held traffic out of the area. The named city area after conducting their ‘investigation’ one hour later reported there were no trucks hung up on any crossing in the named city area. Traffic was released. 15 minutes later the first train released reported they had run through a loaded moving van at a crossing 1/10th of a mile outside the defined limits of the named city.

Where is HERE?

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I have not heard that this washout was discovered and reported by an outside party. From what I read, it was CN that discovered the washout. How did they discover it? Who discovered it?

BaltACD: You do realize the CN (IC) derailment near Rockford was because of a track washout? The road crossing was unfortunately nearby.

If you are out taking pictures of trains and want to know the exact location you are at, check the rr crossing sign, it has the exact rr location and who to call in case of emergency. It is on all the crossings in Canada and according to item #5 in the report should have been there but wasn’t.

  1. " Had the required CN grade crossing identification and emergency contact information been posted at the Mulford Road crossing, the railroad would likely have been notified of the track washout earlier and the additional time may have been sufficient for the rail traffic controller to issue instructions to stop the train and prevent the accident. "

Regular peple using the crossing probably would not know this but police and emergency workers should. Something as simple as a missing tag was probably a major cause of the communication failure.

At least CN paid the $36 M which was deserved and didn’t try and get out of it through some technicality as CP did with their derailment several years ago at Minot, ND. There was a death due to chlorine gas ( I think ). An award of $3 or $4 M was awarded and CP appealed it was exhorbitant and they were exempt and won!

The initial report from the NTSB is very clear and places almost all of the blame on CN as a whole, not any one indivdual. If you sum up the report, the NTSB basically calls the CN incompetent in regards to their safety procedures.

From the new recommendations section of the report:

“12. Implement a program consistent with principles of safety management systems to periodically test all aspects of your internal emergency communication system to ensure that personnel are familiar with the system’s operation and that emergency notifications can be communicated immediately to any chief dispatcher or rail traffic controller in your system.”

I don’t believe that any railroad running ethanol trains through mass populated surburbs of a large city should have to be told to implement a safety program. Does anybody (FRA?) check / verify safety procedures for any / all railroads?

CC

The primary cause of the accident are these related factors:

“The National Transportation Safety Board determines that the probable cause of the accident was the washout of the track structure that was discovered about 1 hour before the train’s arrival, and the Canadian National Railway Company’s (CN) failure to notify the train crew of the known washout in time to stop the train because of the inadequacy of the CN’s emergency communication procedures.”

I thought it interesting that the report mentioned something to the effect that if CN had the phone number posted at the crossing, somebody probably would have called about the washout earlier, and thus CN would have had more than just an hour to notify the crew.

I am fully aware of that - what I am emphasising it that when outside parties - be they police departments or ordinary citizens - report something, anything to a railroad the hardest and most crucial part of the conversation is to understand where HERE is. Locals know their areas in relation to local landmarks. Railroads know their area in relation to mileposts. They are two different languages that MUST be meshed into finding the CORRECT point of the incident - crossing incident, bridge strike, washout - any incident that concerns both parties.

But the point is that the CN was informed of the washout, where, etc. ONE HOUR before the incident and their system failed to inform the train crew.

Funny I read it different. The report said that the washout was discovered one hour before the incident, which is very different than the CN being informed one hour before. I would like to see a full report, with all the conversations and times

~

Now maybe I am missing it, but no where in the report does it say who discovered the washout.

"The National Transportation Safety Board determines that the probable cause of the accident was the washout of th

You are correct about that. Thanks for finding that link to the reporting details. I thought I had read somewhere that CN had discovered the washout an hour before the derailment, but after my last post, it went back to double check the NTSB report, and as you point out, the report does not say that. So I am reviewing what was said where.

I see that the news article linked to the first post here says, “CN knew for an hour about the washout along the tracks near Rockford, but failed to notify a freight train in time to prev

Does anyone have the link to the actual NTSB report?

This is the preliminary report. The final has not yet been released:

http://www.ntsb.gov/news/events/2012/cherry_valley/index.html

from the Register-Star: The initial 911 calls regarding the washout came about an hour before the derailment occurred, where the CN tracks cross South Mulford Road. Despite delays in finding an available law enforcement officer to investigate, Winnebago County Sheriff’s Sgt. Aaron Booker notified the railroad of the damage 20 minutes before the derailment.

CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn.

Only at 8:40 p.m., about four minutes after the derailment, was contact made.

In transcripts of interviews done in Rockford in the days after the derailment, NTSB investigator Russell Gober comments on the 17-minute effort during conversations with multiple individuals tied to the wreck.

“We know that you guys were trying. But your people made three attempts which would, on the third attempt … if Homewood had answered, there would have still be five minutes before the wreck happened,” he said during an interview with Julia Vespoli, a CN police employee.

Investigators also focused on CN’s procedure to warn its trains of inclement weather. Two hours before the derailment, forecasting service AccuWeather issued a severe flood warning for the Freeport area, including Rockford. The alerts come to the Homewood dispatch center via a dedicated printer equipped with an alarm bell to alert staff of the weather report.

That night, however, it’s unclear when the report was delivered to Darnell Parker, the dispatcher in charge of the rail lines around Rockford. Parker never relayed the report to the CN train as it approached Rockford. It’s unclear what effect the warning would have had on the train, as CN procedures only call for engineers to be cautious in light of a flash flood warning, not to stop the train.<

Two new points:

  1. It seems that both locomotives and many loaded tank cars - about 36 + 20 = 56 cars, or half the train - made it over the washout before the rail broke and caused the derailment - simply amazing ! See this transcript of the NTSB’s interview/ deposition of the conductor 2 days later at: http://dms.ntsb.gov/public%2F48000-48499%2F48053%2F460268.pdf

  2. Despite all the rain and flooding that day and night, the train crew apparently didn’t see any need to go slower or stop. See this transcript of the NTSB’s interview/ deposition of the engineer 2 days later at: http://dms.ntsb.gov/public%2F48000-48499%2F48053%2F460281.pdf

I found these interviews from the Rockford Register Star newspaper’s links to them here: http://www.rrstar.com/news/trainderailment/x13287670/Train-derails-National-Transportation-Safety-Board-releases-information

Old point: “CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn.” Bet that’s not the first time that happened ! More likely - a common if not everyday occurrence, which was routinely ‘blown off’ or simply ignored by upper management when called to their attention or when complaints were made - all in the name of ‘efficiency’ by having less than an adequate number of people on duty, of course. When will they ever learn ?

  • Paul North.

As a Rockford, IL resident, I will say that you do have most of the facts straight–the washout happened about an hour before the train got to the crossing. There were severe thunderstorms that passed through the area, dropping a large amount of rain in a short time. A retention pond from a nearby subdivision filled up and then failed, sending a large amount of water down toward the parallel Union Pacific and Canadian National tracks at the Mulford Road crossing.

This exact spot had been the site of washouts–just like this one–that occured back in 2006 and then around 2000. The potential for a problem at this site was well known to the railroad and to local officials, because it had happened before.

Local residents informed the police, who did come out to the crossing and filmed the washout with his dashboard camera, showing the culvert washed out and the tracks suspended for about 20 feet just west of the Mulford Road crossing. The deputy was the one who called the CN to warn them of the situation, but the call went to Montreal and it took them too long to get in touch with the dispatchers in Homewood, IL. I think he called about 20 minutes before the train got there, but I haven’t read the final report. The officer left the scene before the train got there (the Freeport Sub only runs one scheduled freight each direction daily) so it wasn’t like there are frequent trains on the line.

The oddest thing to me is the two locos and 50 some cars made it over the washed out track before the train derailed. Although it was right about sunset–the large amount of standing water near the tracks at the location the crew should have seen something wasn’t right as they approached the crossing.

Lance

First - I have no idea of any procedures that CN may or may not have had in place when this event happened.

With my carrier - the Chief Dispatchers desk for each territory has a physical ‘Emergency Line’ telephone - in addition to the line ringing on the computerized Avtech telephone system, the old dial style telephone with a loud ringer goes off. Instructions are that the CTD will drop any other business or call they may be handling and answer the Emergency Line - IF the CTD is away from the desk for some reason, since the phone can be heard by every Dispatcher in the office - the nearest will answer it. The Emergency Line number is the pre-programmed number that the company police center uses and all outside parties are directed to call it by the signs placed on both sides of every road crossing as well as the police center’s handling with any local emergency personnel (police, fire etc.). The Emergency Line cannot be used to place a outbound call and has no other use than for EMERGENCY COMMUNICATION.

The ringing of the Emergency Line is not to be trifled with and it along with all other telephone lines used by contract personnel in the dispatchers office are on time stamped and recorded line.

[quote user=“Paul_D_North_Jr”]

Old point: “CN’s in-house police force in Montreal, in turn, tried for 17 minutes to reach the railroad’s dispatchers in Homewood, being blocked by busy signals or unanswered phones at every turn.” Bet that’s not the first time that happened ! More likely - a common if not everyday occurrence, which was routinely ‘blown off’ or simply ignored by upper management when called to their attention or when complaints were made - all in the name of ‘efficiency’ by having less than an adequate number of people on duty, of course. When will