DagTSB Report: Flight 214, Quebec Train Disaster

    As Director (acting) of the Dag Transportation Safety Blog, reports on each of two recent transportation disasters are below. For the Asiana flight 214, they say the official NTSB report will be over 900 pages long and take 18 months. DTSB works on a swifter less verbally expansive, 'in your face' manner in issuing reports.

    DTSB Flight 214 crash in SF:

    Report: Pilots were under speed, low in altitude and not anywhere near the glide path, or the descent rate to land safely. Two dead, plane totaled, scores injured.

    Fault: Gross negligence of flight crew and captain for severely blown landing, lack of communication or careless attitude among the pilot crew of 3.

    DTSB Quebec Train disaster:

    Report: 50 missing or dead. Train was parked uphill from town, with air brakes dependent on external motor running to power them overnight. Motor failed, air brakes failed, then train rolled into town, petrochemicals exploded in a fireball.

    Fault: Canadian government: Any train (especially one full of hazardous cargo) left unattended for any length of time, should be required by law to have mechanical brakes set and verified by chief engineer, sufficient to arrest any train movement on any slope on the rail line, without the need for a power source.


    In the USA any train left unattended must have sufficient handbrakes applied to secure the train.  I think the same would hold true in Canada.

    A running motor is not needed to keep the air brakes applied.  Cylinders are pumped up when the system is charged.  The brakes are applied when the air is bled off.  The air holding the breaks can bleed off over time though.

    Train crew error.  The conductor is the boss, not the engineer.

    Sure, blame the crew, that's always easy. Why don't you read the article?

    The article I linked said the air did bleed off the brakes due to motor failure, and you are wrong on the handbrakes:

    ...Air brakes that would have prevented the disaster failed because they were powered by an engine that was shut down by firefighters as they dealt with a fire shortly before the calamity occurred, the head of the railway that operated the train said on Monday...


    .....the handbrakes would not have been strong enough to keep the train in place...

    There was apparently no train crew on duty at the time the cars rolled down the hill. The crew was following SOP.

    Having driven manual shift cars and parked on hills on city streets, you cut the wheels to the curb in case the hand brake fails. It's called 'back-up'.

    Why the rail operator or the government would not require an unattended train loaded with explosive chemicals and parked on a steep grade to not have a heavy and secured dead weight/iron brake/wedge/clamp on the downhill side of the train as a fail safe measure is beyond me. Checked and verified in writing by the CEO of the train crew before leaving the train overnight. I would not pick the guy who handles the luggage.

    Why no regulations on absolutely fool proof securing of parked trains full of hazardous cargo on slopes? Is that a wild impractical idea?

    50 people may have paid for this preventable accident with their lives.

    Likely excuse the usual 'well that's the way we always do it', never been a problem before!


    I'd say you're right that the Canadian (and US) government should be blamed for not having more stringent regulations regarding brakes, but obviously the company shouldn't need regulations to do the right thing (I know, that's Polly Anna-type thinking). This particular company averages about 2 train accidents per year, which surprisingly isn't very high compared to other train companies. Here are some interesting statistics for the US:

    Approximately 1,000 people die in train accidents every year. Further, United States train and railroad accident statistics estimate that almost every two weeks a train derailment leads to a chemical spill. Some of these spills are so serious that they require the evacuation of local residents. The occurrence and frequency of train accidents has been escalating since 1997.
    According to the US Department of Transportation, there are about 5,800 train-car crashes each year in the United States, most of which occur at railroad crossings. These accidents cause 600 deaths and injure about 2,300. More than 50% of all deadly accidents happen at crossings with inadequate safety devices.
    • Every 90 minutes there is a train collision or derailment.
    • A train carrying hazardous cargo derails approximately every two weeks in the United States.
    • Today rail companies rely on technology that was developed more than 70 years ago, and very little research and improvement has been made to update these dated safety measures.
    • Local governments often have no voice over the train traffic in their area, which can result in delays for local emergency responders.
    • According to the DOT’s Federal Railroad Administration, about 80% of railroad crossings do not have adequate warning devices.
    • While vehicle on train collisions have decreased in the past few years, pedestrians involved in train collisions have increased.

    Yeah, 'that's the way we always done it' you expect train guys to change work habits? Over 50 dead bodies, or ashes of 50 dead bodies?

    The apparent scenario in this case, to me, is mind boggling negligent.

    You get the acetylene torch guy and some old rails, cut 'em up, and make triangular 'tank trap' triangle contraption and shove it under the last car on the downhill side at night. You can sleep well knowing the quaint village down the hill won't be leveled overnight due to the explosion of your runaway train.

    I guess the rail company figures in, (or has a legal cap on?), the cost of their stupidity.

    Maybe this tragedy is big enough and clearly preventable enough for them to change how they do things. If they don't, the government should demand it.

    I didn't need to read the article.  I worked on the railroad 41 years, starting in 1968.  I have applied more handbrakes than I care to remember, and it only takes about one per every 10 cars left standing to hold the train.  Trains, which is an engine or engine plus cars with a marker applied to the rear, must be properly secured prior to being left unattended.

    I think I know a little more than you about this subject working as a switchman, conductor, yard master,train master, yard manager along with time investigating train accidents along with writing action plans for retraining.

    Congratulations on your career in rail service.

    It seems some rail employee, and company SOP protocols, which led to this accident may have been executed or produced by folks as self assured as you are, as to proper securing of trains.

    In your 41 years of service, Tom, did you ever read a railroad company safety specification for securing a train of a given weight, on a given slope? Or does each employee just do what he figures will work?

    I believe that the standard procedure is to ask a blogger with no industry experience to google the answer.

    Yes there are specific rules.  They do not list grades vs weight but do specify the minimum acceptable.  You cannot even leave an engine standing alone on zero grade, running or not, without applying the handbrake.  

    NCD, you should do a bit of research before you get emotionally invested in defending your point. Tom, above, was correct in his explanation of how air-brakes on a train work.

    Sure, blame the crew, that's always easy. Why don't you read the article?

    I put up a couple comments yesterday about this accident but I posted to an old blog and they quickly went out of sight so you may have missed them.


    It is counter-intuitive but correct that the brakes are applied by the engineer through the act of releasing air.
     Wikipedia has an explanatory page on air-brakes but I'll try to explain a bit here based on what I know from years of railroading plus the verification I got last night by talking to an old friend who very recently retired after more than forty years as a locomotive engineer. He could not imagine any way that the company spokesman's explanation could be possible.
     The compressor on the locomotive pumps air to a reservoir on each car. From there air is delivered under equal pressure to both sides of a piston which activates the brakes. To apply the brakes the engineer then uses a valve to release air from the car's system. A valve in the cars brake system only lets one side release so the unequal pressure created pushes the piston and the brakes are applied. To release the brakes the engineer reverses his control valve and lets equalizing air be pumped back to the cars brakes. If you understand that you will see that killing the engine can only have the affect of not allowing the brakes to be released because there is now no available pressure to do it with.
     Individual brake cylinders on cars can leak and by doing so release the brakes on that one car. Air-brakes on any one car cannot be trusted or even two or three, but most will hold their charge for hours or days and so the more cars in the train the greater the odds that enough brakes will stay engaged to hold the train in place. For seventy three cars to have their brakes leak off, and also those of the engine which is on a separate system, is like rolling snake eyes seventy three time in a row. You figure the odds.
        ...Air brakes that would have prevented the disaster failed because they were powered by an engine that was shut down by firefighters as they dealt with a fire shortly before the calamity occurred, the head of the railway that operated the train said on Monday...


        .....the handbrakes would not have been strong enough to keep the train in place...

     The RR spokesman who made those two statements was either ignorant or deliberately misleading. My guess, again based on my experience, is that he was both. The first statement I have already explained and the second is just idiotic. The hand brakes on railroad cars are the very same brakes as the ones applied by air during normal operation. Cars that were even semi-modern twenty-plus years ago had efficient gear reduction drives connected to hand wheels to apply those brakes and they could be set as strongly by hand as they could be by air.
     I can see no way that the crew was not at fault for not taking precautionary steps that are standard in the U.S., and I would guess also in Canada, but that still does not explain the rollout. They should have applied hand brakes and a sufficient number of hand brakes, [I would bet five would be enough], would have held the train in place. Here is the current procedure required by the BNSFE when leaving a train unattended. The train is stopped, the air-brakes are applied fully, and hand brakes are set on some number of cars. The air brakes are then released to test that the train will not roll away. Then the air-brakes are applied again. If the engines/s were to be killed or disconnected the only way the air-brakes on the rest of the train could be released would be to bleed off each car separately. In such a case hand brakes, if set would still keep it in place.
     So, even though the crew was apparently negligent, their negligence does not explain the air-brakes failing to keep the train in place. Killing the engine does not either. The fault cannot be placed on the fire crew for killing the engine under any scenario I or my engineer friend could envision.

    As (Acting) DTSB Director, thanks for your commentary. DTSB is always open to new evidence and opinions. Thus far, standard operating procedures for this rail operation are the main focus of inquiry at DTSB, recognizing that the government and the corporation will always seek to absolve themselves of any responsibility for the incident, aiming to pin blame on anyone or anything else.


    Nantes Fire Chief Patrick Lambert said that while his crews tackled the initial blaze, the final locomotive was shut down.

    He said this was the standard operating procedure agreed with the train's US owner, Montreal, Maine & Atlantic Railway (MMA).

    But MMA maintains the decision to shut off the locomotive to put out the fire could have disabled the brakes.

    Can we agree that with such an explosive cargo on such a slope, a heavy and suitably designed iron stanchion/barrier clamped to the rails (with a very big wrench and very big bolts) and in contact with the parked train (on the downhill side) would seem to ensure the train is still there in the morning?

    The advisability of such a precaution would seem to be obvious.

    Um...who appointed this guy? And why wasn't he filibustered?

    I think it was Maiello, my recollection is as shaky as an MMA Railway safety manual, happened when the blog was on temporary holiday recess I guess.

    Quebec train blast: police open criminal investigation as death toll rises:

    ....police Inspector Michel Forget said investigators had "discovered elements" that gave rise to a criminal probe. He gave no details but ruled out terrorism and said police were more likely exploring the possibility of criminal negligence....

    Of course it's criminal.

    Criminal negligence by the US corporation Rail World for 'standard operating procedures' which are a sick joke, and criminal negligence by the Quebec government in allowing these hazardous trains to be parked overnight as if they are sitting on the flattest part of the pancake level Kansas prairie.

    But they'll likely try to blame it on an individual.  Avoiding at all costs legally citing the rail company or themselves, a government not sufficiently active in evaluating, regulating, and mandating safe operations on the public rails.

    Rail World CEO, safety record within standards:

    Edward Burkhardt: "Our operation is entirely consistent within industry standards and our safety records are pretty good.

    I would say something wrong with those standards.


    AP: Railway company chief says employee failed to properly set brakes in Quebec train crash.

    NCD, I'm very sorry, but we've decided to replace you. Please meet the new (Acting) Director of the Dag Transportation Safety Blog:

    Michael, not to throw a wrench in the works, but I'm not sure the rules allow me be replaced in the middle of not just one open investigation, but two.....?

    You dare to defy the blogger formerly known as the great and powerful Genghis! Now pipe down before I make you (Acting) Director of My Ass.

    As you might expect, Quebecers are getting massive coverage of the Lac-Mégantic disaster. Montreal's English-language daily has devoted five to 10 pages a day to the story.

    I've been slow to comment because so much of the info coming out is conflicting. Most of the blame for that goes to the U.S.-based company brass, who have changed their story virtually every day. They have zero credibility. At one point they claimed to have evidence brakes were tampered with; accident investigators say no such evidence was shared with them. So I take their blaming of the engineer with a big grain of salt.

    Rail transport is a federal, not provincial, responsibility. Our Republican-lite government has been deregulating for years, and granting exemptions like the one last year allowing MMA to run single-operator trains. Canadian rules on use of double-hulled tanker cars lag behind even the U.S. A relative who used to drive light-rail trains (they need to learn the same set of rules) agreed an accident like this was bound to happen.

    One thought about the provincial police declaring a crime scene: they were evasive about what crime they suspected until a reporter suggested criminal negligence. They then blocked off views of the site. I suspect their real task is to use their forensic skills to find some trace of the 40 or so people still unaccounted for, and the "crime scene" designation is a legal euphemism. 



    Now they are saying the engineer didn't set 'enough' brakes. Fantastic deduction!

    Rail CEO:

    "I think he did something wrong ... We think he applied some hand brakes but the question is did he apply enough of them," Burkhardt explained. "He said he applied 11 hand brakes we think that's not true. Initially we believed him but now we don't."

    Note to CEO: When the engineer leaves the train, he fills out a 'Securing Train Form'. 

    It has a column for how many cars, total weight, station, slope of track and a simple formula gives the number of brakes necessary to secure the train. He enters in the number of brakes set. and the time set, signs it and gives it to the station master. For hazardous cargo someone else double checks the brakes and signs also.

    Is this rocket science??

    The problem being as I have read, there is no formula, no safety document and no checklist that, apparently, does the math on what 'enough' is when you are parking a huge bomb laden train uphill from a merry little town in the middle of the night.

    It would seem it would not be left to the discretion of a sleepy employee, but would be in writing, and would also include some fail safe back-up.

    Ergo, my suggestion they should by law require a 'rollback preventer', perhaps a recycled 'blowout preventer' from BP's Macondo well. A 50 ton thing on the track would certainly do it.

    Some background on railway CEO Burkhardt and his MO: http://www.thestar.com/news/canada/2013/07/11/lac_megantic_railways_hist...

    Thanks. The Canadian government just last year changed the rule requiring 2 engineers per train to one.

    The company had received approval from Ottawa in 2012 to reduce staffing and operate with only one employee aboard a train, one of only two Canadian rail lines (the other is Quebec North Shore and Labrador Railway) okayed to run with solo engineers.

    Also, an article said to apply hand brakes you must climb up each and every car and turn a wheel 40 times to lock the hand brake, and the engineer checked into the hotel 30 minutes after arriving at the station. Not likely he did too many, but, seems neither the government nor the company care, no rules on it.

    A railroad safety expert in Arkansas thinking along my line from Reuters:

    "I definitely think there should be a protocol ... that addresses where and how you're going to park a train that's loaded with hazardous material," said John Bentley, an accident reconstruction expert in Perryville, Arkansas.

    At present, Canadian and U.S. regulations do not specify the number of handbrakes since factors like track grade, cargo weight and contents, weather and space between railcars can all have a bearing on how many brakes are needed to ensure safety.

    Depending on where a train is parked, more or fewer handbrakes may be required, Canadian Transportation Safety Board investigator Ed Belkaloul said, adding that railroad companies are given some discretion to develop their own safety standard....

    Died due to discretion of some guy on a train. Put it on their tombstones.

    Another rail guy said they should have a 'check curve' before the town, to derail any out of control train before it hits the curve in town. Not going to happen, costs corporations profits.

    50 dead is what happens when neither the government nor the industry have written standards, or even a written record of how many brakes were set, if they were set, and when and by whom. It's called self-regulation, and it is deadly.

    That National Geographic article (your first link above) is a pretty good rundown of the issues that need to be addressed. Here's one that goes into more depth on the DOT-111 single-hulled tanker cars the MMA was pulling:


    It's been recognized since 2009 that their puncture risk makes them unsuitable for dangerous substances. Double-hulled cars would obviously be safer, but DOT-111s constitute the bulk of North American tankers, and the rail industry balked at replacing them all.

    The NTSB proposed retrofitting the DOT-111s to better withstand impacts, but the rail companies said that would cost $1 billion, so the compromise was that all new cars after 2011 had to be built to the safer standard. (Railways made $71 billion in profits last year, BTW.)

    The killer train was transporting fracked crude oil from North Dakota shale to an Irving refinery in Saint John, New Brunswick. It was only today that I realized its most likely route was at least 90% on Canadian Pacific track that runs through my own city, as well as Ottawa and Winnipeg. Scary.

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