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TSB report details chaotic moments surrounding Lac-Mégantic wreck
They put off what needed to be done immediately. If there had been a crew out there with additional motive to get the train to the expected destination, there would have not been a train left unattended. The new owners need to hire more people first.
Thank you fire department for your incompetence. They shut off the engine?! Obviously didn’t know what they were doing.
Carl, you are clueless! Your comment should have been pointed to the employees of the MM&A. It wasn’t the fire departments fault that the engineer didn’t properly do his job. So when they do their job ignorant people like yourself make uneducated comments.
I have a hard time understanding why the engineer left a locomotive which was obviously having problems as the only one running, to run unattended the rest of the night. Just doesn’t make sense to me.
Plenty of blame to go around. Including the aforementioned safety culture. But the dispatcher and especially the engineer stand out as people who really should have known better. The engineer knew the territory (and therefore the grade at Nantes where the train was parked), knew how many handbrakes were set, knew the locomotive was failing, and finally knew it was shut down. He has no excuse. Sorry.
CARL
HAVE TO AGREE WITH YOU
WHOEVER SHUT OFF ENGINE STARTED THIS SENARIO
Justin Franz; great overview.
Here is the link to read multiple TSB reports on the accident. You can read the summary or get into the weeds reading the full investigation and laboratory report.
http://www.tsb.gc.ca/eng/enquetes-investigations/rail/2013/r13d0054/r13d0054.asp
Section from the summary report:
The engineer applied hand brakes on all five locomotives and two other cars, and shut down all but the lead locomotive. Railway rules require hand brakes alone be capable of holding a train, and this must be verified by a test. That night, however, the locomotive air brakes were left on during the test, meaning the train was being held by a combination of hand brakes and air brakes. This gave the false impression that the hand brakes alone would hold the train.
The engineer then contacted the rail traffic controller in Farnham, Quebec, to advise that the train was secure. Next, the engineer contacted the rail traffic controller in Bangor, Maine, who controls movements for the crews east of Lac-Mégantic. During this conversation, the engineer indicated that the lead locomotive had experienced mechanical difficulties throughout the trip, and that excessive black and white smoke was coming from its smoke stack. Because they expected the smoke to settle, it was agreed to leave the train as it was and deal with the situation the next morning.
Shortly after the engineer left, the Nantes Fire Department responded to a 911 call reporting a fire on the train. After shutting off the locomotive’s fuel supply, the firefighters moved the electrical breakers inside the cab to the off position, in keeping with railway instructions. They then met with an MMA employee, a track foreman who had been dispatched to the scene but who did not have a locomotive operations background.
Once the fire was extinguished, the firefighters and the track foreman discussed the train’s condition with the rail traffic controller in Farnham, and departed soon afterward. With all the loco
Carl and Earl, weak logic. Let’s say the fire department didn’t go to the locomotive and it kept on burning. What are the chances it would have continued running until the next crew arrived? If it shut down, who would you blame when the unit was clearly in trouble when the engineer left? The real issue is who could have directly prevented the disaster, and the clear answer is the engineer by settling the hand brakes according to the rules.
WORN BRAKE SHOES MAKE HUMAN POWER INEFFECTIVE…HUMAN COULD TURN BRAKE WHEEL WITH ALL HIS MIGHT BUT WORN BRAKE SHOES DO NOT APPLY FULL BRAKING…
IF BRAKE SHOES ON CARS WERE NEW
DIFFERENT RESULT…
Anybody who blames the fire department for what happened is just showing they don’t work on the railroad or they are a complete idiot. The railroad dispatcher from what I’ve read drop the ball in this case. Let’s send a track laborer not a Qualified operating employee ie and engineer/conductor to see if the train is ok? Give me a break. My thoughts and prayers continue to go out to those effected by this horrible and yes Avoidable accident.
At first it seemed as if the fire was trivial and that the firemen triggered the entire affair. But now… with all the additional facts, it is clear that not enough hand brakes set properly were what allowed the train run away. The dispatcher is also at fault- but this only points up the problem with remotely located personnel being unable to truly comprehend what was actually happening at the scene, and therefore making bad decisions based on incomplete information.
John Odom,
I have to agree with you in part. Engineer Harding stated that he left the malfunctioning lead unit, #5017, running and shut down the other four locos in the consist. It would seem logical for him to have chosen one of the other locos that were operating properly and shut down 5017 instead. On the other hand, Harding has to be gven credit for offering to go back to Nantes and start another locomotive to maintain brake pipe pressure as soon as he was told by the dispatcher that 5017 had been shut down by the fire dept. after it caught fire. It was the dispatcher who turned down the offer and said, in effect, to leave it for the morning and the incoming crew. On the other hand, Harding stated that he tied-on a total of seven handbrakes (the five locos plus two other cars) before leaving the scene. He also applied the independent brake. Why did he not operate the train brake and apply brakes on the entire consist instead? Finally, not sure what the MM&A’s operating rules require, but were seven total vehicles’ handbrakes sufficient to restrain movement of the entire train in a yard whose physical characteristics (downgrade leading toward Lac-Megantic) well-known? Clearly, Harding thought so, but his judgment was gravely in error. Perhaps if the presumably tired Harding had the assistance of a second crew member, the extra handbrakes would have been applied. Critics of the government’s willingness to reduce train crews to one person warned that additional accidents would result from halving the available manpower on-hand. It is foolish to believe that one person can do all of the work necessry to operate a long, heavy freght train, especially one laden primarily with HAZMAT.
Regarding the Nantes firemen. No blame to them. They followed their SOPs and took the correct action. I know, I’m a NYS certified firefighter of 40 years and have been there, done that with both Metro North and CSX (both operate through my fire district.)
In any case, if they had left it burning it would have shut itself down eventually. And no one in their right mind would fight a fire with the engine running.
So no matter what the firemen did that engine was shutting down.
If the engineer’s lack of application of enough hand brakes was an anomaly, it might be justified to think about blaming him. However if it was common practice not to apply enough handbrakes (as rumor suggests, whatever that is worth) and if that was the guidance from Harding’s supervisors, then there was a systemic problem that is to blame. I haven’t heard if this was detailed in the report, but I imagine it would come out as part of Harding’s criminal defense.
Probably shouldn’t have fixed that cam bearing saddle with J B Weld.
Like most major manmade disasters, the Lac Megantic one is the result of several things going wrong in a deadly sequence. Change one or two things in the scenario and the disaster never happens. Look at NTSB investigations. The trouble is the general public and politicians want to blame somebody. In this case, it looks like the engineer, who obviously made some mistakes, is going to take the heat.
What sets the cars brakes is not lack of air, it’s “rate” of depletion. Each car has a control valve, effectively the brain of the brake system. When the engineer makes a reduction this valve senses the rate of depletion and sets the brakes either conventionally or into emergency. Because the brake pipe was only reducing about 1psi per minute, the control valve didn’t sense a large rate of reduction, thereby it didn’t set the brakes. This is a simple explanation. Hope it helps. As far as who’s at fault, unfortunately, myself being an engineer, I have to say the engineer. He didn’t release the independent (engines brakes) after tying the handbrakes when he did his brake test. Had he did this, the train being held by 2 cars handbrakes plus 5 engines would’ve started to move. The fire department bears no blame for shutting the power down. It was a “perfect storm” that night and unfortunately everything bad lined up right. This could’ve and should’ve been prevented. So sad. I feel bad for everyone involved, including the engineer, who’s forced to live with this the rest of his life. No winner’s here.
It is interesting that the safety board placed had very few comments about the Nantes Fire Dept.
Rural firemen (probably volunteers, mostly) often place their lives on the line for the communities they serve. Putting out the fire (as described) and shutting down a problematic engine would seem to be a proper course of action, lacking any guidance from knowledgeable, on site, railroad personnel. They did perform their service by extinguishing the fire and shutting down the engine to prevent a fire reoccurence - consistent with their mission.