Canadian Railroads > Safety culture...

1.22.4 Securement of trains (MMA-001) at Vachon

Shortly before the accident, MMA-001 was parked in the siding at Vachon by a Brownville
Junction single-person train operator who was to be assigned to MMA-002 the following
morning. MMA-001, consisting of 5 locomotives and 98 residue tank cars, had been secured
with 5 hand brakes, and the independent brakes were applied. The locomotive cab door was
not locked, and the train’s paperwork along with the reverser were sitting on the locomotive
console. The minimum hand brake requirement for a train of this length, as per MMA’s
instructions, was 11 hand brakes.

A relevant question to train operations management might be:

>>How often, in the 90 days prior to the Lac-Megantic incident, did you or a person reporting to you, verify that the company's directive on the number etc of brakes tied down was in fact being implemented? How many trains were checked, etc?

The report states that when there were two-person crews, the rules tended to be followed all the time, but that there were many shortcuts taken when single-person operations were involved.

Ray

Ray_Murphy Wrote:
-------------------------------------------------------
> The minimum hand brake requirement for a
> train of this length, as per MMA’s
> instructions, was 11 hand brakes.

MMA-01 was the train of empties going in the direction opposite of MMA-02, which is the one that ran away. The MM&A rule cited in the report is truncated but most railroads specify the number of hand brakes as a guideline. The crewman securing the train makes a final judgement call based on location, grade, weather, and weight of train. I do it all the time.

Again, the train mentioned here is empties. Five properly applied brakes may have met the "sufficient hand brake" requirement provided a test was properly conducted and those five brakes passed by holding the train with all air brakes released. If it fails the test, you simply add hand brakes until it holds. Loads will obviously require more braking force to hold the train than empties. Applying the brakes with a good set under it provides more mechanical braking force than tying brakes on pistons that are fully released. You have to know what the hell you are doing. There is really interesting graph explaining this on page 178 of the report.



Edited 1 time(s). Last edit at 08/20/14 10:25 by trainjunkie.

A number of years ago, the company I work for had the compliance manager do a study of about five years of reportable accidents and injuries in a our shop setting. These results are approximate, but you will get the idea.

5% The number of incidents where employees were ordered or encouraged to use unsafe methods.

10% The number of incidents that were far enough out of the realm of normal comprehension, that it was unlikely ANY safety rule or policy could have prevented it.

10% The number of incidents where employees were simply ignorant of safe and proper procedures that should have been covered by employee training.

25% The number of incidents where employees were simply ignorant of safe and proper procedures that were job skill related "common sense" skills that are generally NOT covered by employee training or handbook.

50% The number of incidents where employees willfully disregarded known proper procedures and practices for their own personal expedience.

10% The number of incidents where management had direct or indirect knowledge of a unsafe activity and did not intercede.

90% The number of incidents where management was unaware that an an unsafe operation was being undertaken until after the fact.

You get what you inspect, not what what you expect

Lackawanna484 Wrote:
-------------------------------------------------------
> You get what you inspect, not what what you expect

Uh...Ray has brought up a very valid concern here about one-man crews. So what are the shortlines, and later the Class Ones to do? Hire the same amount of managers at the field level to replace the conductors? I can ASSURE you that the existing level of managers do inspect parked trains, but have enough going on in large terminal areas and many other areas that they do not have TIME to go behind each employee to make sure that proper train securement has been done.

Good Grief!!! And I ever glad that I'm Safely RETIRED from this industry!!! Which used to be pleasant at times--or at least a few more good days than bad. But a bucket of horse dung for all future employees, and the young ones. "Change is inevetiable; Progess is NOT."

And with the In-Cab Cameras and the ever-increasing rules and the prospect that PTC (without ANY industry-wide standards or implementation agreed upon), and the Frank Wilmer, Railway Age, and AAR crowd all shouting at the top of their lungs that the time for one-man crews is here, and even some TE&Y crews hollering that they'll sell their souls for an extra $90 bucks a day, I have no doubt that the BN/UTU/SMART Agreement will pass, then spread! And that the Class Ones will pay off who they have to pay off to get it done. And that the 13-year old kids on here (99% of whom have no interest whatsover in becoming railroaders, perhaps a small percentage wanting to just become accountants or something--and guess what--ALL of your jobs for those of you youngsters that have ANY interest in becoming rails will never be because of the increasing level of what former Chairman of the Fed Paul Greenspan called "Creative Destruction"--and--the "Picture-Takers" that have no "skin in the game," will in fact WELCOME one-man crews, or even automative (Oh man, that's cool!...as they face a future of flipping hamburgers or selling shoes or something at minimum wage? And yes, even with a college degree--most new rails HAVE a college degree, folks!!! Plus have served in the military in heroic positions, faced horrific dangers, and even as officers!!!...not that I'm saying that an officer is any better than a well-trained enlisted man in any branch of the service, but just one difference between college and no college: officers have generally gone to college while enlisted men/women have not, but all have SERVED & VALIANTLY, and do in fact deserve first shot at RR Employment, IMHO). Yes. But not knowing the dangers of it what's upcoming. I only wish that somebody could more intelligently put this into words that I can?

And, I've written on another thread(s)--and elsewhere in other venues--when parking on severe gradients in a siding per the GCOR, well, what is the one-man crew to DO whether it's a Crude-by-Oil train, a Haz-Mat Train, or even a Manifest Train: WHAT is the single man or woman to DO in the middle of the required process of tying down a train after getting off the locos, then tying down the "sufficient number of cars," then going back to the head end and kicking off the train air (automatic brake valve), for the TEST, and the train goes rolling past them?!? WHAT ARE THEY TO DO?!? All they can do is to alert the dispatcher to call 9-11, and shout frantically (if they can get ahold of the drastically overloaded dispatchers that have more territory that can be practically covered), is indeed to shout: "Runaway Train! Runaway Train!!!" Be afraid, those of you that live within two or three miles of a mainline...be VERY AFRAID!!! And just HOPE that the cops and/or fire department will knock on your door at 3:00AM and wake you and your Family up and get you up in time to EVACUATE and out of your home in time to get out of your place of residence!!!

And it's all so unnecessary. And if you think that the RRs, their boards, the large investment groups, or their CEOs care about YOU or your families, then you're living an "Alice in Wonderland" life. And this from one who has loved his RR career very much, but, sickened to heart by the new procedures and proposals, and the Railway Age/Frank Wilmer crowd--along with the AAR (Association of American Railroads)--who are lobbying the Congress very hard, and I mean HARD--to STRIP the FRA of rule-making abilities with regard to rule-making abilities. And yes, the FRA is the Federal Organization that in association with the Association of American Railroads that has historically written and revised the General Code of Operating Rules (GCOR). And then you have the pie-in-the-sky folk that don't think we should have ANYBODY on the headends of trains?!? And yes yes yes! They'll rewrite the GCOR to suit their needs! Have no doubt about this!

And yet, in the face of the RR Industry, by self-announcement (and all you have to do is get any of their Annual Reports), is making more profits than in the history of said industry, and has been quarter-by-quarter for the last two decades). Yet, the cash-strapped airline industry? Which is barely making ends meet, with record bankruptcies? Zero calls to eliminate the copilot position whatsoever, none! And even new rules on at least U.S. carriers, that if the pilot or copilot must get up to use the restroom, must call a flight attendant up to occupy his/her seat until that's accomplished. And keep in mind--those of you that are frequent airline travelers--every single flight that you take, even if it's a "Regional Jet," flies all the way from takeoff to destination on AutoPilot, and if landing at any airport of consequence with "CAT III" landing abilities, which most all of those have, the plane "Lands Itself" on AutoLand. So you are flying, and landing, with the AutoPilot doing all of the work!!! Just as U.S. Navy fighters land themselvs onto the decks of USN Aircraft Carriers, with the pilots of such only required to "manually land" X-Amount of daylight and nighttime landings per month. But ZERO call for cutting out the copilot position on domestic U.S. air carriers!!! And as mentioned on several threads here and across the spectrum in other venues, PTC will NOT aid whatsoever in tie-down accidents, and/or in a variety in other accidents.



Edited 3 time(s). Last edit at 08/21/14 00:30 by Red.

Red Wrote:
-------------------------------------------------------
> Lackawanna484 Wrote:
> --------------------------------------------------
> -----
> > You get what you inspect, not what what you
> expect
>
> Uh...Ray has brought up a very valid concern here
> about one-man crews. So what are the shortlines,
> and later the Class Ones to do? Hire the same
> amount of managers at the field level to replace
> the conductors? I can ASSURE you that the existing
> level of managers do inspect parked trains, but
> have enough going on in large terminal areas and
> many other areas that they do not have TIME to go
> behind each employee to make sure that proper
> train securement has been done.
>
> Good Grief!!! And I ever glad that I'm Safely
> RETIRED from this industry!!! Which used to be
> pleasant at times--or at least a few more good
> days than bad. But a bucket of horse dung for all
> future employees, and the young ones. "Change is
> inevetiable; Progess is NOT."
>
> And with the In-Cab Cameras and the
> ever-increasing rules and the prospect that PTC
> (without ANY industry-wide standards or
> implementation agreed upon), and the Frank Wilmer,
> Railway Age, and AAR crowd all shouting at the top
> of their lungs that the time for one-man crews is
> here, and even some TE&Y crews hollering that
> they'll sell their souls for an extra $90 bucks a
> day, I have no doubt that the BN/UTU/SMART
> Agreement will pass, then spread! And that the
> Class Ones will pay off who they have to pay off
> to get it done. And that the 13-year old kids on
> here (99% of whom have no interest whatsover in
> becoming railroaders, perhaps a small percentage
> wanting to just become accountants or
> something--and guess what--ALL of your jobs for
> those of you youngsters that have ANY interest in
> becoming rails will never be because of the
> increasing level of what former Chairman of the
> Fed Paul Greenspan called "Creative
> Destruction"--and--the "Picture-Takers" that have
> no "skin in the game," will in fact WELCOME
> one-man crews, or even automative (Oh man, that's
> cool!...as they face a future of flipping
> hamburgers or selling shoes or something at
> minimum wage? And yes, even with a college
> degree--most new rails HAVE a college degree,
> folks!!! Plus have served in the military in
> heroic positions, faced horrific dangers, and even
> as officers!!!...not that I'm saying that an
> officer is any better than a well-trained enlisted
> man in any branch of the service, but just one
> difference between college and no college:
> officers have generally gone to college while
> enlisted men/women have not, but all have SERVED &
> VALIANTLY, and do in fact deserve first shot at RR
> Employment, IMHO). Yes. But not knowing the
> dangers of it what's upcoming. I only wish that
> somebody could more intelligently put this into
> words that I can?
>
> And, I've written on another thread(s)--and
> elsewhere in other venues--when parking on severe
> gradients in a siding per the GCOR, well, what is
> the one-man crew to DO whether it's a Crude-by-Oil
> train, a Haz-Mat Train, or even a Manifest Train:
> WHAT is the single man or woman to DO in the
> middle of the required process of tying down a
> train after getting off the locos, then tying down
> the "sufficient number of cars," then going back
> to the head end and kicking off the train air
> (automatic brake valve), for the TEST, and the
> train goes rolling past them?!? WHAT ARE THEY TO
> DO?!? All they can do is to alert the dispatcher
> to call 9-11, and shout frantically (if they can
> get ahold of the drastically overloaded
> dispatchers that have more territory that can be
> practically covered), is indeed to shout: "Runaway
> Train! Runaway Train!!!" Be afraid, those of you
> that live within two or three miles of a
> mainline...be VERY AFRAID!!! And just HOPE that
> the cops and/or fire department will knock on your
> door at 3:00AM and wake you and your Family up and
> get you up in time to EVACUATE and out of your
> home in time to get out of your place of
> residence!!!
>
> And it's all so unnecessary. And if you think that
> the RRs, their boards, the large investment
> groups, or their CEOs care about YOU or your
> families, then you're living an "Alice in
> Wonderland" life. And this from one who has loved
> his RR career very much, but, sickened to heart by
> the new procedures and proposals, and the Railway
> Age/Frank Wilmer crowd--along with the AAR
> (Association of American Railroads)--who are
> lobbying the Congress very hard, and I mean
> HARD--to STRIP the FRA of rule-making abilities
> with regard to rule-making abilities. And yes, the
> FRA is the Federal Organization that in
> association with the Association of American
> Railroads that has historically written and
> revised the General Code of Operating Rules
> (GCOR). And then you have the pie-in-the-sky folk
> that don't think we should have ANYBODY on the
> headends of trains?!? And yes yes yes! They'll
> rewrite the GCOR to suit their needs! Have no
> doubt about this!
> (snip)

I'm sorry that you misunderstood my comment. Every good manager in the world knows you don't hand out a new rule book, and then go out and play golf. You --inspect-- what's actually being done, and resolve issues where the rules and actual practices are at variance. You don't just --expect--that everybody understands everything in the book, and it works perfectly.

You can have the best rule books in the business, you can have the best training people and classes, but if you don't monitor what's actually happening in the field, you'll have problems.

It sounds like MM&A left practices in the field to the people running the trains. Mr Harding acknowledged not seeing or having important directives, and there seems to be no practice for assuring they were given to him.


(The banking and insurance industries have had this problem for years. The government issues a new rule, the company issues a new practice, the guys in the field continue doing things mostly as they have been. Unless you're monitoring, watching some sample of actual transactions, interviewing customers, etc you'll have problems.)

Red Wrote:

> And, I've written on another thread(s)--and
> elsewhere in other venues--when parking on severe
> gradients in a siding per the GCOR, well, what is
> the one-man crew to DO whether it's a Crude-by-Oil
> train, a Haz-Mat Train, or even a Manifest Train:
> WHAT is the single man or woman to DO in the
> middle of the required process of tying down a
> train after getting off the locos, then tying down
> the "sufficient number of cars," then going back
> to the head end and kicking off the train air
> (automatic brake valve), for the TEST, and the
> train goes rolling past them?!? WHAT ARE THEY TO
> DO?!? All they can do is to alert the dispatcher
> to call 9-11, and shout frantically (if they can
> get ahold of the drastically overloaded
> dispatchers that have more territory that can be
> practically covered), is indeed to shout: "Runaway
> Train! Runaway Train!!!" Be afraid, those of you
> that live within two or three miles of a
> mainline...be VERY AFRAID!!! And just HOPE that
> the cops and/or fire department will knock on your
> door at 3:00AM and wake you and your Family up and
> get you up in time to EVACUATE and out of your
> home in time to get out of your place of
> residence!!!
>

Why would the single crewman be on the ground after releasing the air brakes? As I picture it, they would be on the locomotive, sense the movement upon releasing the brakes. They would re-apply the air brakes before leaving the cab to go crank on more hand brakes, and then try it again. The folks that write the rule books aren't stupid.



Edited 1 time(s). Last edit at 08/21/14 21:57 by radar.

Lackawanna484 Wrote:
> Red Wrote:
-------------------------------------------------------
> > Lackawanna484 Wrote:
>
> Every good manager in the world knows you don't
> hand out a new rule book, and then go out and play
> golf. You --inspect-- what's actually being done,
> and resolve issues where the rules and actual
> practices are at variance. You don't just
> --expect--that everybody understands everything in
> the book, and it works perfectly.
>
> You can have the best rule books in the business,
> you can have the best training people and classes,
> but if you don't monitor what's actually happening
> in the field, you'll have problems.

> (The banking and insurance industries have had
> this problem for years. The government issues a
> new rule, the company issues a new practice, the
> guys in the field continue doing things mostly as
> they have been. Unless you're monitoring,
> watching some sample of actual transactions,
> interviewing customers, etc you'll have problems.)

> --------------------------------------------------
> > > Red Wrote:

> > > > > You get what you inspect, not what what you
> > expect
> >
> > And with the In-Cab Cameras and the
> > ever-increasing rules and the prospect that PTC
> > (without ANY industry-wide standards or
> > implementation agreed upon), and the Frank
> > Wilmer, Railway Age, and AAR crowd all shouting at the
> > top of their lungs that the time for one-man crews
> > is here, and even some TE&Y crews hollering that
> > they'll sell their souls for an extra $90 bucks
> > a day, I have no doubt that the BN/UTU/SMART
> > Agreement will pass, then spread! And that the
> > Class Ones will pay off who they have to pay
> > off to get it done.

Let me take a stab at it from my own perspective. I think we share some views on some of this.

I somewhat agree that you get what you inspect, not necessarily what you expect. In the information technology field that I work in, it is accepted practice that important changes to systems are reviewed and approved by technically competent peers and managers. The procedures are pretested, and the results are post-tested again after being implemented. The system is risk-based: the higher the risk, the greater the procedural oversight and approval requirements. Bottom line: anybody who works in the field gets used to having their changes thoroughly reviewed. It's just part of the deal. If you're offended by that, you may want to find another line of work.

Some changes are implemented so regularly and with such repeated success that they become standard. Their risk as a result is lower, and they therefore have a reduced level of testing and approval associated with them.

That is (surprise!) a measure of success. Getting a change procedure to the point that it can become standardized like that is a plus. It's not a slide-by, or a skirting of the rules, or getting by easy. Young people coming into the field sometimes have a hard time grasping this. In our youth, we tend to see less oversight as our success in sliding by, bending the rules, or getting by without someone noticing. But when you have your process and governance working the right way (read: rules on the railroad), having something work well consistently enough that compliance is consistent is a mark of a good process.

By persistently and rigorously reviewing, testing and approving over time, something moves down in risk and up in trustworthiness. And it may thus eventually require less oversight, testing and level of approval. So, you do get what you inspect: both at first by inspecting over and over, and ultimately too with less inspection because the process has risen to a level of trust that more intense inspection is no longer as necessary.

And, yes, if somebody screws up, the risk goes up again, the trust goes down, and everybody returns to Go on the Monopoly board -- but without $200.

I'm no railroader. But it seems to me that this principle carries over to railroading. New operating pattern, new rule, new general order, supervision is all over it (as they should be) making sure it works and that compliance is good. As it works out (maybe after some adjustments) and compliance rises to a consistent and target level, the risk to either efficiency or safety (or both) is perceived to be reduced, and inspection is reduced. That should be the goal. And when you're there, you have the situation you describe, Red. You don't have to have a supervisor standing behind every employee -- a scenario no one should want, and which you rightly question. You don't have to (should I say it?) monitor the cab with an inward-facing camera (a loathsome thought in my book). You don't have to have heavy-handed discipline, and screaming supervisors bursting into a cab following an efficiency test (a la some stories here on TO).

Until, yup, someone doesn't get the message. Back to Go. No $200. Maybe even Go to Jail.

To Lac Megantic: It totally busted the trust. There was way too much risk in the operating procedures that were followed, from securement, to location, to the poor locomotive condition that led to the fire and the bleed off of the independents. But here's the thing: it had apparently been done often enough that it had risen to the level of becoming standard. That's why even when things have risen to a level of perceived lower risk and higher trust, they still need to be reviewed periodically. Compliance still needs to be checked (as you said Red, tied-down trains still need to be inspected regularly for compliance, even when overall compliance is good). And trainmasters do, yes, still have to hide in the weeds and do efficiency tests.

But -- and this is crucial -- you still have to be alert for surrounding external conditions that would make what would be standard and low risk most of the time suddenly high risk in one instance. What did that mean for Lac Megantic? Surging locomotive, oil leaking, maybe means trouble. Work with the DS, tie down this time on a level spot instead if possible. Tie down more handbrakes this time. Be extra sure you make that test against the hand brakes to assure securement. When the fire was reported and the engine shut down, tie down more handbrakes or take other actions to assure securement, including staying with the train and getting assistance out there until securement could be assured in whatever way necessary.

Ronald Reagan was right: trust but verify.

Many rails have pointed out on this board many times: something can always go wrong. What has risen to become usual, common, standard, generally low risk and trusted can become risky and dangerous in an instant due to the specific circumstances of the here-and-now. That's why you "keep your head on a swivel" on the ground, stay alert in the cab, talk and learn from each other, and qualify and re-qualify so that your actions to be safe and stay safe become well practiced. And yes, carriers, it's why (stockholder, and former transportation worker speaking here) you MUST deal with the crew rest issue comprehensively and systemically. There's way, way, way too much risk baked into the present practice. It must change.

To one-man crews: I have very serious doubts about them. But we will never know if they can work and can be trusted, that they can work well for crews or not, or that they are too risky and cannot be trusted either for safety, efficiency or the benefit of workers, unless it's tried under competent, rigorous, well-governed process. I know, I know: let the camel get its nose under the tent and the whole tent will eventually come falling down. Pandora's box, wedge in the door, slippery slope, watch that first step, give 'em an inch and they'll take a mile -- pick your favorite adage for taking a risk.

But sorry, Red, Frank Willner may be right. Or he may be dead wrong. Either way, he's forgotten more about railroading than many people have ever learned, so I find it hard to discount his view. But without a serious trial we'll never know. (and yes, lots of on-their-toes watchfulness by the unions to keep the camel from pulling the tent down -- can they, will they, really do that?). Again, trust but verify.

And yes, the young 'uns have got to be educated by the old heads at what's at risk. They MUST take the long view, and not just think about today. Young folks inherently aren't good at that, and they are on the other hand risk-takers by nature, in spades. And they are inherently way too ready to compromise. They just don't know what they don't know (even though they think that they do). The old heads have to learn 'em: trust but verify. And be totally willing to say no if the risk is too great.

One thing's for sure: technical advancement will come. The underlying technologies coming into the scene in cloud computing, analytics, cognitive computing and mobile that will come to fruition in applications now and in the not very distant future are spectacular, and potentially highly disruptive. The industry has the capital to invest in them today, and the marketplace will demand that it does. For rail labor, it will indeed be a time to lead, follow or get out of the way. Frank Willner seems to suggest that it should lead, and participate in building the future environment. He just may be right.

> > And that the 13-year old kids
> > on here (99% of whom have no interest whats over in
> > becoming railroaders, perhaps a small
> > percentage wanting to just become accountants or
> > something--and guess what--ALL of your jobs for
> > those of you youngsters that have ANY interest
> > in becoming rails will never be because of the
> > increasing level of what former Chairman of the
> > Fed Paul Greenspan called "Creative
> > Destruction"--and--the "Picture-Takers" that
> > have no "skin in the game," will in fact WELCOME
> > one-man crews, or even automotive (Oh man,
> > that's cool!...as they face a future of flipping
> > hamburgers or selling shoes or something at
> > minimum wage?

I'm with you, Red, wondering and despairing a bit about that world to come. And you're right: young people are, unfortunately in my view, too smitten with technology for their own doggone good. They see only the upside, and seldom the risks. For me it's a terrific tool that can spectacularly enable growth and efficiency, and I've had a great career with it in that context. But for them it's an entire way of living. They've never really thought through about what kind of world an all-overarching technical environment will be like. They've never recognized that every bit of information is a two-sided coin, and can be used to enable, or to deny. Yup, there's that old bogey man risk again. Never goes away, somehow.

Me, I still want a world where we work for work's sake and to contribute to our society and culture. Where skill, consistency and delivering a great product still count, and build us up with a sense of worth, accomplishment and pride that is the glue of society and culture. It can be better that there's a human hand on that throttle and brake valve, or doing any number of other things. And in so many things it's better for us to do it through human action than through a machine's action. Maybe machines can do all of that and we can all just kick back. Sorry, I do not want it. Work is hard, it's painful, it's often tiring and frustrating, and risky to boot. But without it we all lose so, so much more than we will ever gain.

It's worth the risk. Always has been. Always will be.

MC
Columbia, Missouri



Edited 1 time(s). Last edit at 08/22/14 06:03 by ironmtn.

Nicely said, MC. Very eloquently stated.

I don't think there's any doubt that Red, me, and all of us want a safer culture where everyone understands what their job entails and has the tools to do the job in a safe manner. That doesn't happen by accident, and it doesn't happen by brutal discipline. It happens with trust, confidence, and understanding.