Oil train disaster in Lac-Mégantic, Québec 07-06-2013

butts260 wrote:Mr Norman, did Wolfgang Amade call you to Salzburg?

Off topic response to Mr. Butts; hard to believe, but I only heard one work of Wolfie while there. That was the Adagio from Trauermusik K 477.Otherwise two concerts were Bruckner symphonies and the third was of Baroque sacred works.

The long awaited report from the Transportation Safety Board of Canada is due to be released on August 19. A press conference will be held in Lac-Mégantic at 10:30 a.m. EDT that day.

http://www.tsb.gc.ca/eng/medias-media/a ... 140805.asp" onclick="window.open(this.href);return false;

TSB report is out.
Release: http://www.tsb.gc.ca/eng/medias-media/c ... 140819.asp" onclick="window.open(this.href);return false;
Report: http://www.tsb.gc.ca/eng/rapports-repor ... 3D0054.asp" onclick="window.open(this.href);return false;

“Accidents never come down to a single individual, a single action or a single factor. You have to look at the whole context,” said Wendy Tadros, Chair of the TSB. “In our investigation, we found 18 factors played a role in this accident.

The TSB found MMA was a company with a weak safety culture that did not have a functioning safety management system to manage risks. The TSB also learned that Transport Canada did not audit MMA often and thoroughly enough to ensure it was effectively managing the risks in its operations. Furthermore, the Board found problems with training, employee monitoring, and maintenance practices at MMA; with industry rules for the securement of unattended trains; and with the tank cars used to carry volatile petroleum crude oil.

Bottom line, only the 5 locomotives and 2 cars had hand brakes applied, that wasn't enough to hold the train when the air brakes leaked off. The hand brake test was made with the locomotives' air brakes applied.
Comment from me: "Even if more air brakes had been applied, like the emergency brakes on the cars, the train would have still run away when they leaked off, as not enough hand brakes were applied."

So the engineer lied when he was asked how many hand brakes he applied?

The 2 cars with hand brakes applied were the caboose between the 1st and 2nd locomotives and the box car between the locomotives and the tank cars.

Understood. I thought I saw something somewhere, months ago, in which the engineer claimed to have applied more brakes than that... I can't recall the exact number but I thought it was 7 or 9 or something similar (which still would've been grossly insufficient). Does anyone else remember that or am I imagining things?

Also, the C30-7's had a Quick Release Brake valve which was designed to vent the air from the R#2 brake cylinder when applying the handbrakes. The second loco in the consist, MMA 5026) did not have a functional QRB, so the handbrake application did not have the required effect. (Fm pge 25 of the TSB Canada R13D0054 report). The valve had 'non-standard' repair work done to try and make it functional. MMA's Summary Operating Bulletin 2-276 addressed this issue, but the engineer stated he wasn't familiar with that document. (pp 26, ibid). No date was listed for when Bulletin 2-276 was issued.

The TSB has released a 3D animation of what happened that night.

You can view it here: http://youtu.be/wVMNspPc8Zc" onclick="window.open(this.href);return false;

Some other findings: The SD40-2's in the consist were equipped with an Auto-Start Feature that would've brought a unit online when the air pressure dropped too low. However, they were electrically isolated by the engineer, so the Auto Start wound up being disabled...

There were Reset Safety Controls (alerters?) in the GE's which were retrofitted by a previous owner. The wiring on each was different, and the 5017's was wired directly to the battery. The RSC's were supposed to activate a penalty brake application once the circuit breakers were thrown, but this did not happen due to the wiring configuration on the lead unit, which was provided w/power as long as the battery still had charge. According to the TSB, there was no *requirement* to test the RSC to determine if a penalty application would happen when the breakers were opened. I *suppose* this is because the engineer wouldn't normally take the lead unit off-line if it was the only operating unit in a consist....

The cause of the engine failure and fire on 5017 was traced to a 'non-standard' repair of the boss for one of the cam bearings in Oct. 2012. An epoxy-type material was used to build up a damaged area of the boss (approximately 45 degrees of arc), rather than welding or other repair methods. The bearing is an annular ring and when tightened, the "repaired" area did not have enough compressive strength, so it leaked oil. This led to it being tightened further (in the Derby shop on 15 March 2013), which applied unequal stress on the cam bearing, which affected the lubrication to the adjacent cylinder's valve train. Once the cam bearing failed, a valve broke, dropped into the bore and holed the piston, which allowed engine oil to be propelled into the exhaust system and turbo housing. This was what caused the fire, approximately 10 minutes after the engineer left the scene. (pp30-31 of TSB Report).

I've only skim read, but it basically says that the accident was due to the engineer not applying enough handbrakes, as per the rules. However it is pretty scathing of the whole management culture at MMA, from engine repairs as noted above, to safety training, risk assessment, auditing, employee supervision, track maintenance, etc. You name it - it was lacking.

OMG Killer Locomotive Nearly Sold Off By Bureaucrats Shocker !!1!
http://www.thestar.com/news/canada/2014 ... _sold.html" onclick="window.open(this.href);return false;

(see the subhead)

In bureaucratic fashion, the report blames the agency responsible for oversight of railroads. This is like blaming the inspector for the bad product that somebody else made.

PBM

If it's the inspector's job to protect the public from unsafe products and the inspector fails to do that, is he blameless?

I think there's plenty of blame to go around for all parties involved.

MEC407 wrote:If it's the inspector's job to protect the public from unsafe products and the inspector fails to do that, is he blameless?

I think there's plenty of blame to go around for all parties involved.

Heartily agree. This accident was caused by multiple failures on the part of multiple people.