Canadian Railroads > All the blame in one pie chart

https://twitter.com/salimah_shivji/status/501738412211466240/photo/1

Doesn't include percentages, though.

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It's going to be hard for the parties who are blaming it all on the engineer to succeed.

Ray

Two more excerpts from CBC's reporters' tweets:


"This was a company with a weak safety culture, a company where people did what was needed to get the job done rather than always following the rules. A company where unsafe practices were allowed to continue." Wendy Tadros, TSB chair



Seven handbrakes were set initially. A fire broke out in the engine of one of the locomotives. Emergency responders shut off the engine, cutting off the independent airbrakes. The handbrakes weren't enough to hold the train.


BobE

Sad to see an improper hand brake test done. Knowing nothing of MM&A procedures to test the hand brakes I am assuming it is similar to the testing done at CSX that would have prevented movement when all else failed. Yes, I know what assuming does. Sure would like to read MM&A's procedure to that. Thanks BobE for posting this right away.

All those bubbles and not a single one mentioned the fact that it was ran and tied down by a single employee. If there were two crew members on that train the risk of it not being tied down properly would have been cut in half.

Posted from Android

The railroad would focus on two of the blue bubbles and claim all the other bubbles to be inconsequential. Other agencies will look at the bigger picture.

Certainly if the railroad was a Class A operation many of the bubbles would not be factors. However since this was not Class A in so many ways the train securement bubbles become absolutely critical. What had worked to "secure" the train on the grade in the past became inadequate when the locomotive caught fire.

Posted from Windows Phone OS 7

I'm no expert, but it would appear that if the handbrake effectiveness test had been conducted properly the train would likely not have run away. And as far as the TSB's new "physical defenses" go, how about simply putting a couple of chains around a few wheels in addition to applying sufficient hand brakes?



Edited 1 time(s). Last edit at 08/19/14 09:20 by wlankenau.

wlankenau Wrote:
-------------------------------------------------------
> I'm no expert, but it would appear that if the
> handbrake effectiveness test had been conducted
> properly the train would likely not have run away.

True.

> And as far as the TSB's new "physical defenses"
> go, how about simply putting a couple of chains
> around a few wheels in addition to applying
> sufficient hand brakes?

Chains, chocks, skids, etc. would have done nothing to prevent movement of this heavy a train on that much of a grade.

jkchubbes Wrote:
-------------------------------------------------------
> All those bubbles and not a single one mentioned
> the fact that it was ran and tied down by a single
> employee. If there were two crew members on that
> train the risk of it not being tied down properly
> would have been cut in half.
>
> Posted from Android

That's an impossible assumption to make. Two crewmembers can (and sometimes do) choose or fail to follow proper procedures just as easily as one. This was a case of using a half assed method of securing the train that he had likely gotten away with many times UNTIL something else went wrong. While there are PLENTY of reasons that a one person crew may or may not be a good idea, making this incident an indictment of one man crews is to totally miss the point.

junctiontower Wrote:
-------------------------------------------------------
>making
> this incident an indictment of one man crews is to
> totally miss the point.


After reading other media reports etc, I come away with the impression that the TSB blames two organizations - Transport Canada and the MM&A.

Where are Ed Burkhardt's defenders now?

Will MacKenzie
Dundas, ON

Well I look at it this way. First off, the engineer flat screwed up. Two, he got rather bad advice when he called in the malfunctioning lead locomotive. I don't know how you blame anybody for that except the person that gave it. I have to wonder if that person was fully aware of the scope of the locomotives problems. Third, I blame the MM&A for their rather lackadaisical approach to their training and certification. I think the accident STILL happens even if those shortcomings did not exist, because the engineer had a rule book AND enough experience to know better, but you can't give the railroad a free pass for not following the guidelines. Where does Burkhardt fit in? Well IF you can make the case that the MM&A's weak safety culture was a result of his decisions, or that he had knowledge of these short comings, then yes, you can extract your pound of flesh. IF, on the other hand, the poor safety culture and record keeping was a result of errors made at a lower level without Burkhardt's knowledge, then no, but either way, you are pretty much going to get what so many of you are snarling for, because Burkhardt is pretty much ruined, and at his age, it's unlikely he will ever recover what he has lost, financially or otherwise. Throwing blame in any other direction than what I have outlined above, is just obfuscating the facts, usually for some political agenda or another.



Edited 2 time(s). Last edit at 08/19/14 11:27 by junctiontower.

jkchubbes Wrote:
-------------------------------------------------------
> All those bubbles and not a single one mentioned
> the fact that it was ran and tied down by a single
> employee. If there were two crew members on that
> train the risk of it not being tied down properly
> would have been cut in half.

The posted graphic is idiotic. It did not come from the report, but from someone who thought it would be a useful visual. It isn't. Read the full report. There is a long section covering single-person crews.

I agree that the chart is idiotic when it lists things like "Excessive speed for track". That's a result of the incident, not a cause of it, and "train left unattended at the top of hill", is not against any rules, and is not a problem if correct procedure are followed.



Edited 1 time(s). Last edit at 08/19/14 12:24 by junctiontower.

All the contributing factors and no one specific solution.

Sounds so very normal.

And these results are not law, only a series of reccomendations


Simple solution which would cripple the rail tranport of many goods:
ban all those tank cars with DOT 111
factors and only use the new designed for safety rolling stock.
No DOT 111 rolling stock be allowed in international/across
the border service.
A decision of that nature would certainly encourage the construction
of "the" pipeline.

As to the human factor, sh*t happens and in this case it most
certainly did. Placing individuals in jail will not return
a certain town in Quebec to as it was. Ideally the former
MM&A line should be embargoed and never be allowed
service until the track is at least to a 25mph status and holding;
which would more than likely ensure total abandonment;
which of itself might not be a bad idea.

There are other routes and methods for tranport of such product.

Bryce Lee

The extent of the 10 mph slow orders is breath taking. Although the track is nominally 25 mph, very little of it was operated that way.

This is a classic example of a failure chain. You can start at any point, and reasonably display a high probability of dire consequences one or two steps later:
-poor maintenance of the locomotive leading to the fire, etc
-extensive slow orders require the overnight stay, etc
-poor rule / safety culture / training of the RTC or managers
-no qualified people available to respond to a serious on the road issue
-failure to grasp the implications of a locomotive on fire
-unwillingness to invest in a new siding on level ground as the oil train business picked up
-and so on

I'm not aware of any other railroad segments where oil, chemicals, haz-mat etc move at 10 mph over such long distances.

junctiontower Wrote:

"Excessive speed for track". That's
> a result of the incident, not a cause of it,


I reply:

Actually, it is a factor.

If that train had gone through Lac-Megantic at 10 mph, it wouldn't have derailed, would it?

You are apparently trying to read the TSB's bubble graph for only the causes of the train running away, whereas the TSB is trying to show the whole chain of events from the runaway to the fatal explosions.

BobE

Yes, but the train wasn't supposed to be going through town AT ALL! To list it as a contributing factor suggests that the track should be upgraded to be able to handle a train as fast as it can run away down the hill. Everybody is making this WAY TOO HARD. If you properly secure the train, it doesn't matter that the locomotives were junk, or that the track was junk, or the cars aren't strong enough. If a 747 falls out of the sky and flattens a house killing a family, do you list the fact that the house wasn't built strong enough to support a crashing 747 as a contributing factor in the deaths?

The TSB does not assess "blame." It explains causes.

Best regards,

Rob L.

junctiontower Wrote:
-------------------------------------------------------
> Yes, but the train wasn't supposed to be going
> through town AT ALL! To list it as a contributing
> factor suggests that the track should be upgraded
> to be able to handle a train as fast as it can run
> away down the hill. Everybody is making this WAY
> TOO HARD. If you properly secure the train, it
> doesn't matter that the locomotives were junk, or
> that the track was junk, or the cars aren't strong
> enough. If a 747 falls out of the sky and
> flattens a house killing a family, do you list the
> fact that the house wasn't built strong enough to
> support a crashing 747 as a contributing factor in
> the deaths?


Your comments always make waaaay too much sense. It's almost comical sometimes to read your comments that make perfect sense to me, but sometimes fall on deaf ears.

I frankly don't understand the discussion on the poor track conditions and the call to embargo the line due to poor track as it relates to this incident. To me, it has NOTHING to do with this incident. NOTHING. A runaway train killed 47 people, not poor track. In fact, that the 'poor' track held the train until a sharp curve should dismiss any discussion of poor track as an issue in this incident. Also, 10mph speed to haul hazardous cargo would be safer than a 60mph speed, correct? ???

I think the biggest factor is the idiotic decision to park a hazmat train at the top of a grade overnight. True, if there are enough handbrakes set, the train should not run away (if the brakes work), BUT if you park a train on level ground, the train will never run away, NO MATTER WHAT!!! You don't have to rely on a human to set 'enough' handbrakes or rely on the mechanicals to function as intended. It seems like a stupid risk to do what they did. There were other options to handle this train over the route that may have cost a few more bucks, but wouldn't have incinerated 47 people. Good God.

trainjunkie Wrote:
-------------------------------------------------------
> wlankenau Wrote:
> --------------------------------------------------
> -----
> > I'm no expert, but it would appear that if the
> > handbrake effectiveness test had been conducted
> > properly the train would likely not have run
> away.
>
> True.
>
> > And as far as the TSB's new "physical defenses"
> > go, how about simply putting a couple of chains
> > around a few wheels in addition to applying
> > sufficient hand brakes?
>
> Chains, chocks, skids, etc. would have done
> nothing to prevent movement of this heavy a train
> on that much of a grade.


Chains, chocks and skid would have done something, if they had been applied correctly.
Their purpose is not to stop a rolling car, it's to prevent it from rolling in the first place.
If they're placed right against the wheel, like they were designed to do, it is very hard for the wheel to start rolling.