Derailment and fire in Quebec

[dave1905]

I understand the independents weren't released on the train that ran away.  I was asking if they set the handbrakes in the same manner and released the independents when they re-enacted the incident.

[JT42CWRDriver]

One thought (and yes, I know, this *is* supposition) - was there an (incorrect) assumption that the loco independant brakes gave the same braking force as applying the handbrakes on the loco's? That would lead you towards expecting there to be no difference between doing a pull test with the independant released versus doing it with the independant applied.

I'm not sure about a C30-7, but if they are similar to UK locos the independent brake would give more braking power because it applies the brakes on all the wheels rather than the handbrake which is only on one truck or even one or two wheelsets in some cases.

[Adrian Wintle]

I'm not sure about a C30-7, but if they are similar to UK locos the independent brake would give more braking power because it applies the brakes on all the wheels rather than the handbrake which is only on one truck or even one or two wheelsets in some cases.

 

From the report:

1.10.1.1 Locomotives

There are no requirements for a locomotive to hold any other equipment when the hand brake is applied. On many locomotives, including the ones in this accident, when the hand brake is applied, only 2 of as many as 12 brake shoes are applied to the locomotive wheels.

 

Adrian

[Glorious NSE]

I'm not sure about a C30-7, but if they are similar to UK locos the independent brake would give more braking power because it applies the brakes on all the wheels rather than the handbrake which is only on one truck or even one or two wheelsets in some cases.

 

Agreed, i'm just wondering if there's a reason why some MMA crews thought it was fine to do it the way they did (other than, it's a handy shortcut)...

[Glorious NSE]

I understand the independents weren't released on the train that ran away.  I was asking if they set the handbrakes in the same manner and released the independents when they re-enacted the incident.

 

• The total retarding brake force required to hold the train on the grade where it was parked at Nantes was calculated to be approximately 146 700 pounds.
• The total retarding brake force generated by the 7 hand brakes on the train (taking into consideration that the QRB valve did not trip on MMA 5026) was approximately 48 600 pounds. Had the QRB valve been operative, the total retarding brake force would have increased by 4830 pounds.
• At a brake cylinder pressure of 27 psi, when the train first began to move, the retarding brake force of the independent brakes was reduced to approximately 97 400 pounds.

 

I'm not a physicist, but I reckon that given the handbrakes were providing less than a third of the force required to hold it there, it should have moved fairly convincingly. That's not a hmmm, it might move, it might not, kinda number...

[Ozexpatriate]

Fairly simple I think Michael - it says it all in your first two quotes.  Unless ALL the power brakes, including the loco independent brake (often referred to in the UK as the straight airbrake), are released the effectiveness of the handbrakes in holding the train will not have been tested.

The procedural laxity on the MMA which might have made the LE realize that the locomotive independent brakes were still on would be attempting to move the train while tied down with handbrakes. I could not find in the report whether this was attempted and it does not seem to be universal practice on the MMA.

 

One of the other sad coincidences here is that had the LE spent a mere ten more minutes applying handbrakes or attempting to move the train while it was tied down or any other delay, he would have been there when flames became evident on the locomotive and (hopefully) would not have left the scene.

Edited August 22, 2014 by Ozexpatriate

[The Stationmaster]

The simple situation in British operation is that when stabling the straight airbrake should not be relied on to hold anything, and certainly not to hold a train (or part thereof), because there is a strong likelihood that it will leak off and cease to be effective as a brake.  It would seem that simple precaution was not followed by the Engineer of the train which ran away into Lac Megantic.

 

An interesting thing in all of this - not exactly relevant to the runaway - is what happens when a train secured in this way is restarted.  Presumably the auto airbrake is applied or is it assumed the loco independent brake will hold the train while the handbrakes are released?

[dave1905]

Automatic airbrake would be used.

[dibber25]

That, I think, absolutely sums it up.  Safety is basically simple, it rarely costs very much extra once you have your procedures established and the point about the responsibility of managers is very well made - that is why they are there and that is why they are paid to manage.  

Similarly your further point, and I quote - 'I think the keys are operational management (ie. staff training, safe systems of work, maintenance etc) and asset state.' - is very pertinently made, if you can't get those things right you shouldn't be running a railway, or indeed any other sort of industrial or transport process. 

 

I'm afraid that Bok's comments are - in some respects - a little worrying and betray something of a 'not invented here' syndrome which can affect all sorts of things and opinions (and not just in the USA/Canada of course).  Safety and safe working methods should be absolutely basic in any railway operation anywhere - if you don't start from that premise and if you don't continue to keep it as a basic part of your operating procedures  a 'Lac Megantic incident' is simply looking for its time to occur.  Securing any train properly when it is left unattended, on any line but especially on a running line on a gradient, is so basic that to get it wrong and not to do the job properly must inevitably lead to big questions about the competencies and management of the organisation in which it happened, all the way to the top.

 

Incidentally I have been involved in railway operating, at many levels including latterly specialisation in operational safety, both within the main UK industry and subsequently in private industry and consultancy roles (on several different gauges) in the UK and Austalia for in excess of 40 years.  So I do happen to know a bit about safety management and safe operation of railways (including the operation of the heaviest freight trains running daily in Britain) - which is something which the official report has concluded could clearly not be said of the MMA.

In 35 pages of comment we have discussed at great length the behaviour of staff, the infrastructure, the railway company and, to some extent the TSB. In my view, standing in the background of what happened is Transport Canada. Read the reports about how they failed to get remotely near their own targets for railway inspections, for instance. I seem to recall it was something like 150 against a target in the thousands. MMA needed to have been subject to a lot more scrutiny from above. In general, one doesn't favour having 'regulators' breathing down the neck of organisations but effective management has to come from the top down - from the VERY top. But part of the problem is that the show is run by people from the industry and maximising profits and maintaining the organisational status quo seems to be the order of the day.

I guess the 'tit-for-tat' thing is to be expected but in pointing out the quality and success of accident investigation in the UK, I certainly wasn't trying to start a who can pee highest contest. Railways will always have accidents - humans make mistakes. What is important is that we learn from those mistakes and take action to avoid repeats. Herald of Free Enterprise was mentioned. After that, ferries were not allowed to purge fumes from the car deck by sailing with the bow doors open. No one said, "we've always done it that way, so it must be OK," or "the Captain didn't do the job right". I suspect (I haven't checked) the door gear is now interlocked so that you CAN'T sail with the doors open. I don't see that kind of approach coming, yet, from TC.

CHRIS LEIGH

[jjb1970]

In a sense the Herald of Free Enterprise is a text book example for a serious accident with multiple causes.

 

The media concentrated on the bow doors and it is absolutely true that sailing with open bow doors to reduce the turn around was the immediate cause. The media did give some attention to the corporate culture of TT/P&O (I actually felt sorry for P&O as they'd just bought TT and were not responsible for TT's culture but it was the P&O name that garnered all the disapprobation) which was driving such short turn arounds leading to unsafe practices. There was some attention to manning levels and hours of work but not that much. The part that was not really appreciated by many was the inherent vulnerability of Ro-Ro type vessels to free surface effects on the vehicle deck. Since failure of a bow door is an entirely foreseeable event (even if it wasn't the result of deliberate action) then the question is why did regulators, class societies etc accept these designs in the full knowledge of their vulnerability? 

 

In 1994 the ferry Estonia went down with a truly shocking loss of life (852 dead) due to failure of the bow visor and subsequent catastrophic loss of stability. That was 7 years after the Herald of Free Enterprise. The vulnerability of Ro-Ro vessels was known before the Herald of Free Enterprise. The UK made efforts to secure international agreement for new Ro-Ro construction standards and found few if any supporters. After the Estonia there were changes to the SOLAS Convention but more fundamental improvements to Ro-Ro stability were limited to those countries who signed the Stockholm Agreement, this is not a general standard. 

 

 

After the Herald of Free Enterprise the UK Carver Report recommended formal safety assessment for shipping and applied much of the same rationale as was proposed over 20 years earlier in the Robens report to shipping. This despite a lot of effort is still not really accepted by the maritime industry despite an IMO resolution supporting formal safety assessment. This may surprise people but there is no requirement for anything like the equivalent of a safety case for a ship. You build to prescriptive classification society rules and meet applicable statutory requirements and if those standards are not great then it is somebody else's fault. I regularly get told by ship yards (and I'm not talking about the bottom feeders) that they are not interested in formal safety assessment, it adds cost, it adds uncertainty and as far as they're concerned it adds no benefit. 

 

There is a concept called the "swiss cheese" model which is a nice easy to comprehend way is illustrating that almost all accidents happen because of a result of multiple failures, the swiss cheese slices representing safety barriers all line up in such a way that the holes are all aligned too so there is a clear path through all of the barriers to create a disaster. Whilst it may seem simplistic it is a very good way of reducing the argument to something anybody can understand. In the Herald of Free Enterprise multiple things lined up:

 

the inherent stability problems of Ro-Ro designs

the practice of using draught from airflow through open doors to ventilate the vehicle decks

manning levels

lack of interlocks or indicators on the bridge

a sea state that meant the waves would enter the vehicle deck

 

And other factors too. Corporate cultures generally are difficult to quantify but in my opinion are absolutely fundamental. At a certain level the fact that regulators allow designs with a high level of vulnerability does not prevent operators building above minimum standards whilst the commercial pressures that drive bad practices tend to come down from high levels.

[jjb1970]

On the role of Transport Canada, there is a general issue with many regulators that they are under resourced and what resources they do have are often squandered on whatever the political idea of the day is and business process tasks. Another issue is that in many cases the prosecution budget is so small that everybody knows that even if they're caught by a regulator the chances of real consequences are minor. 

[The Stationmaster]

The situation in Britain would seem to be different in a number of ways.  First any organisational change which affects the operator's Safety Case has to be risk assessed (although I honestly wonder to what extent some operators have done that in the past and there was a definite case of one - now departed - who didn't).  Secondly most (all?) operators still have independent audits carried out although generally they are procedural audits although they sometimes include practical audit as well.  And thirdly all operators employ Inspectors of various sorts for internal standards checks.  Most of that has effectively carried on from the situation BR reached although external operating procedure audits did not exist then.

 

In addition to that there are the two other bodies.  RAIB (Rail Accident Investigation Branch) basically do what their name says for certain categories of incident and their main methodology has been to concentrate on procedural matters (i.e. whether procedures exist to prevent such an incident and whether they were followed and whether they should be changed or new procedures adopted) rather than the old HMRI approach of investigating first the cause and then making recommendations to avoid recurrence.  Finally there is the HMRI - now very different from the traditional view of them and who again mainly have an interest in procedures - whether they exist and are applied etc - but in current application rather than in consequence of investigating an incident.  However when visiting HMRI Inspectors also usually look at practical matters as well as procedures and will, in effect, check whatever in order to assess if procedures are being applied - they have very considerable enforcement powers and can. literally, shut the job down on the spot if they consider that appropriate while they also have powers to apply Improvement Orders.

 

Translating the MM&A into the British situation would firstly involve the company getting it right, and monitoring that it was getting it right, internally.  Then having external audit of its procedures and, possibly their application.  HMRI would, hopefully, at some time get round to visiting and assessing them and this could well happen following a report from somebody - the first target of such a visit would inevitably be the company's SMS (Safety Management System) and if they didn't have one or it was inadequate they would either be given a deadline to get it sorted or be forced to cease operating.  The railway element of the Lac Megantic incident would be investigated by RAIB.

[jjb1970]

Something I will give the USA is that of all the national delegations at IMO the US is the only one which is made up entirely of staff drawn from regulatory agencies such as the EPA and the USCG. And their delegation is extremely highly respected for the technical competence and capability of its members. Every other national delegation that sends anything more than their permanent representative relies on people seconded by industry, such as classification societies technical specialists (me), ship builders, engine builders, ship owner representatives etc etc. Now for the most part those seconded from industry bring the technical experience and knowledge that national delegations need and cannot source from internal resources, but there is always the question of who those people are representing. I like to think that in working for an industrial provident society I'm free of commercial pressures to push regulations for the benefit of local ship owners and such like but even in my case there is no doubt that my employer has its own interests which I am expected to safeguard. If you ever observe the voting and plenary interventions then there it can feel very much like the Eurovision song contest.

[Gerald Henriksen]

Trial of three ex-MMA employees has started:

 

https://beta.theglobeandmail.com/news/national/actions-of-three-ex-railway-employees-caused-lac-megantic-disaster-crown/article36457100/

[jjb1970]

Crikey, that was a big locomotive.

[Gary H]

Crikey, that was a big locomotive.

Quite. You'd think that after 4 years and millions of words written on this sorry saga  these journo's would have a basic grasp of the facts by now!

Just after the "10'000 ton locomotive", the train is refered to as a convoy.

[dibber25]

Quite. You'd think that after 4 years and millions of words written on this sorry saga  these journo's would have a basic grasp of the facts by now!

Just after the "10'000 ton locomotive", the train is refered to as a convoy.

 

Sadly, few newspapers or TV channels, these days, have specialised transport correspondents. The story will be covered by a general reporter whose work will be trashed and re-written by sub-editors who will have a different set of criteria and will be mainly concerned with 'how it reads'. Standards have been slipping for the past 50 years and more. (CJL)

[jjb1970]

The thing that always worries me is that we rely on journalists and the news media to inform us about what is happening in the world and that shapes our views of the world.

 

In most cases where I've read a story in the media about an event or subject I'm familiar with the media version is at best flawed and as often as not nonsense. OK, the subjects and stories I'm familiar with are probably not the sort of things a typical journalist could be expected to know much about, but that doesn't fully explain some of the idiocy I read. And on the subject of emissions it is pretty obvious many of the stories the media does run are planted either by engine makers or the green NGOs are I quite often recognise the syntax and am pretty sure I could name the actual author.

 

And in some ways even worse are the rent-a-gob tame "experts" who do sort of know what they're talking about (or should do) but decide to take the money by offering good quotable stuff on demand.

[BR60103]

I find that often after I read the story I have no idea what they were trying to say. Sometimes I can translate into terms that I understand, but ...

[peach james]

The OK the PK version (* CBC Quebec) was far more readable- I suspect that a fair amount of English-French-English has gone on in the Globe article.  

 

http://www.okthepk.ca/news/oct2shortline2017100301.htm

 

James

[peach james]

So, the jury is now sequestered, and some very interesting bits come out that they weren't told...

http://www.cbc.ca/news/canada/montreal/lac-m%C3%A9gantic-rail-disaster-1.4481968

 

(for more detailed coverage, go to http://www.okthepk.ca/megantic/index.htm )

 

I have an opinion, but it is rather political for here...

 

James

[pH]

All three MMA employees accused of criminal negligence at Lac Megantic acquitted:

 

http://www.cbc.ca/beta/news/canada/montreal/lac-megantic-criminal-negligence-verdict-1.4474848

[Gary H]

So,

who is accountable then?

[Oldddudders]

So,

who is accountable then?

 

It is clearly seen as a culture thing - safety simply wasn't high enough on MMA's agenda, and resources were too thinly spread. The fact that the mayor of the devastated city recognises the accused were not really at fault says it all. 

 

In the wake of Clapham, and the findings of the Hidden Enquiry, there was a wholesale overhaul of safety procedures throughout BR, as well as a parallel examination of whether criminal acts had been committed. This is comparable, except that MMA has disappeared, although its officers are still in the frame. 

[Gary H]

It is clearly seen as a culture thing - safety simply wasn't high enough on MMA's agenda, and resources were too thinly spread. The fact that the mayor of the devastated city recognises the accused were not really at fault says it all. 

 

In the wake of Clapham, and the findings of the Hidden Enquiry, there was a wholesale overhaul of safety procedures throughout BR, as well as a parallel examination of whether criminal acts had been committed. This is comparable, except that MMA has disappeared, although its officers are still in the frame. 

I did get the impression that the whole MMA  set up was run on a shoe string with much penny-pinching and a 'just about making do' management culture whilst the guys on the ground struggled with worn out, hand me down junk!

Whilst I'm glad that the engineer and his immediate colleuges were not thrown under the bus, I do think the 'officers' of MMA should have been prosecuted in some way or another. 

In some ways it reminds me of the way Railtrack was run leading up to our own catastrophes here.