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Trains News Wire FLASH: TSB identifies systemic problems leading to Lac-Mégantic incident, calls for rail safety improvements
Very tragic chain of events, it so sad so many people died because of so many little things that lead to one huge problem. Shortcuts eventually lead to tremendous consequences.
No mention of the cargo?
The cargo contributed to the death of 47 souls. If this was just a manifest train then there may have been fatalities but in no way would it have even approached 47. However the real story here is the operating practices. I don’t see how any tank car standard will keep tank cars from rupturing that derail at the speeds this train was going. We are all thankful for automobile safety standards but we all realize that irresponsible operation can still lead to death.
the fact that the engineer, fire crew, and the railroad all were at fault says something about the lack of coordination and safety. The cargo was oil this time, but could of been something far worse like chloride gas, propane, or any other chemical that could react violently when combined with water or air. Rail is still the safest way to transport these things when it is done properly. Train crews and first responders need to be properly trained.
The concept of a one man crew leaves the lone individual accountable only to himself. Add another man, then both are accountable to each other. Add a third man…you get the point.
A “weak safety culture” is a function of little accountability.
Why mention the cargo? Because cause and effect are linked. If this train had been with lumber, or coal, or pretty much anything else this wreck would have been a blip on the news rather than the incineration of 46 people.
For those who wish to read the report, it is available on line. It answers a lot of questions, and corrects much of the speculation found on the forum in the past.
http://www.tsb.gc.ca/eng/rapports-reports/rail/2013/R13D0054/R13D0054.asp
I agree with Mr. Harrison, except for his implication that the entire “railroad industry” are apologists for MM&A or that their safety culture is equally lax. I see no evidence for this, and I expect (but of course can’t prove) that this would not have occurred on any of the 7 Class 1s.
File this one under “Well, duh!”
As soon as it became obvious that MM&A parked a train at the top of a hill on the mainline with no derailer and whose locomotive was on fire with the full knowledge of everyone involved, it became obvious that there was a safety culture problem with that railroad, regardless of how many handbrakes were set.
“Ed” got defended anyway. People went off on tangents, from conspiracy theories about pro-pipeline environmentalists to blaming firefighters for following standard procedures in fighting the engine fire.
Maybe now the industry can move forward and stop coming up with excuses. I lost a lot of confidence in the railroad industry’s safety culture when I saw the apologism being done for MM&A amongst so many railroad people. Yes, the NTSB frequently goes overboard, but, you know, maybe the reason why the Acela Express is built like a tank is because the NTSB and FRA doesn’t trust the railroading industry enough to run things safely, and sees making passenger rail uneconomically resistant to incompetence as the next best thing.
Todd Schultz - the cargo is an important element for consideration in any risk management system. Lack and/or failure of a risk management system was cited as causal by TSB so inclusion of the cargo is appropriate.
Over-regulation can breed a culture of short-cutting safety regulations… It seems to create an environment of which regulations are important in a specific circumstance…“Who” will make that specific determination for a given set of circumstances? The train crew or the dispatcher, or management? It seems that invariably, too many rules and regulations seem to lead to a case of picking and choosing the most effective…The ignored rule may be the one that causes the problem. Someone mentioned that there was no derail. would a so called portable derail have done the job? Should the railroad have sent an employee out to check on the train while it was parked? There have been statement in the ‘FORUMS’ around here that the “GCOR is written in the blood of railroad employees and crews”. You can bet this flurry of rule-making will be broken at some point, and the GCOR will grow by more rules made to cover those circumstances.
Why would they mention the cargo? It was not the cargo that caused the accident, it was failure to apply enough handbrakes.
Everyone seems to over look the fact that even with a one-man crew, there are two employees who knew how many hand brakes had been applied on a parked train. The crewman who took over or picked up a train also knows how many hand brakes he had to release to free the train. Mr. Harding had been failing to put more than a couple hand brakes on the cars of the oil trains he left for over a year. There are many M&MA employees who will hide their guilty conscience of their failure to not have turned in the bad performance to the officials. One case the rules examiner was told but the official did nothing to correct the problem.
The Lac Megantic accident was caused by there being no management Train Master on 300 miles of railroad in Canada who would have done safety checks on the crew securing proper brakes on the cars stopped at Nantes. The TM was based in US and was on vacation, job blanked.
The trackman that pushed the off button on the one engine was out of his authority if he could not have started another engine to maintain the same air brakes. He also said that he assumed the hand brakes were applied without check that question. A qualified trainman would have checked that. The engineer, Mr. Harding, when checking into the Hotel called his dispatcher and asked to return to the train but was told to stay at Hotel and get his rest. That was another bad call since there was no management at the train at that time.
Railroad crewmen in America now have a rule whereby, if they discover an unsafe action like this, it becomes their responsibility to report it to management, regardless of the consequences upon the prior crewman performance. As example, The Metro North system in New York has opened a “snitch (safety) phone line” but they don’t call it that.
After reading the report, it looks like the one person who was calling the shots, the Farnham RTC, made several bad calls. Several of his decisions and instructions multiplied the risk to the point of failure. It looks like both the “on site” people wanted to “do something” and he told them not to.
After reading the report, it looks like the one person who was calling the shots, the Farnham RTC, made several bad calls. Several of his decisions and instructions multiplied the risk to the point of failure. It looks like both the “on site” people wanted to “do something” and he told them not to.
For about 95 years, Canadian Pacific did crew changes at the station in downtown Megantic (see the videos on YouTube). But when the Shortlines took over, the town forced them to stop delaying road traffic for 10 minutes at a time on the level crossings by doing the crew changes on the hills at Vachon or Nantes.
The rest is history.
Ed Jordan.
Lunenburg NS
Has it ever been established who released the automatic (train) brakes? Shutting down the locomotive would certainly cause the engine brakes (straight air) to leak off, but the train brakes would not have released from leakage in that short amount of time.
From the report, it appears the engineer himself released the automatic brakes after the initial application, relying only on the independent and handbrakes to hold the train on the grade.
When the locomotive was shut down, the independent brakes started leaking and eventually released.
Why ever routinely “park” a train to begin with, especially in such a location and with flammable cargo? As to snitching, therte is no such thing when it comes to preventing loss of life.