I haven't read about an accident on the railroad in the last 48 years where I haven't said to myself: "This should never have happened."
I can't imagine any railroad operating officer thinking anything but "This should never have happened" when reading about a train accident on a railroad. If an officer does think something to the contrary of that, get rid of him or her, not because he or she is going to cause an accident, but because he or she won't learn the lesson from the tragedies that have befallen others in our industry.
That is not the same thing as saying "We have zero-tolerance for risk. We have zero-tolerance for train accidents." Of course we have tolerance for risk. Our jobs are all about managing that risk, achieving a reduction in risk, so that risk can in fact be tolerated; so that it is contained before it wrecks trains, wrecks lives, wrecks families.
Every fatal railroad accident that I know about has been preceded by a warning:
"Something's wrong, here. We just took that 30 mph curve at 50."
"Something's wrong here That crew had to put the train in emergency to prevent a runaway on the descending grade."
This should never have happened:
"The occurrence: On 4 February 2019, Canadian Pacific train 301-349 was proceeding westward to Vancouver when 99 cars and 2 locomotives derailed at Mile 130.6 of the Laggan Subdivision near Field, British Columbia (B.C.). The train crew consisted of a locomotive engineer, a conductor, and a conductor trainees. The 3 crew members were fatally injured."
The circumstances: The train was a unit grain train consisting of 112 grain hopper and 3 locomotives configured as distributed power (DP). There was a locomotive at the head end, another in the middle of the train, and a third one at the very end. DP is a good thing, allowing faster and more uniform application and release of the train brakes as the air brake system is charged from multiple locations, and the distance the air has to travel to control braking effort is reduced.
DP also allows for smoother application of power, and the reduction of in-train forces, particularly important when handling long trains over ascending and descending grades. DP has contributed to the increased average train lengths of the last decade. And that's good too.
As good as DP is however, it cannot compensate for....extreme cold, and worn or defective components of the train braking system.
And it was cold on 4 February when the 3 person crew showed up in the middle of nowhere to take over a train that had been standing in -30 Fahrenheit temperature for approximately 3 hours. Freeze your forehead cold. Turn your tears to ice with your eyes closed cold.
Now I'm not a mountain railroader. I am flatlander from Chicago who has lived and worked just about at sea-level and below on the East Coast. The tallest mountain I had to negotiate in the cold was Oak Island Hump. But... I do know a little bit about cold, being from Chicago, and working in New Jersey.
I know that extreme cold can impair, and even crack the rubber gaskets that feed the air through the train and into the brake system.
I know that extreme cold can cause the moisture that is in the air as it is compressed and pushed through the trainline, to condense, freeze and interfere with air flow and the proper movement of the train's brake valves.
I know that operating in extreme snow and cold conditions can encase the brake riggings and the brake shoes that actually apply the pressure to slow the wheel, with ice, making it "problematic" (hate to use the word "impossible") to stop.
Once, in just those conditions, we had to stop a locomotive that was running away from its engineer by lining it into the hump classification yard, and "catching" it in the retarders. The locomotive engineer told us he had no brakes and he was right: the brake riggings and brake shoes were encased in ice. "Problematic," I said to the yardmaster after we stopped the locomotive. "Insane," said the yardmaster. He had a union, he could be a little more blunt-spoken.
I also know we had car limits on trains when the temperatures dropped below a certain level (I forget what the exact marks were), but at times we were limited to 75 or 80 cars on trains to Conway, Pennsylvania, or Buffalo, NY. That was before distributed power, but then we never dealt with 30 below temperatures.
So call me backward, but I think 112 cars is probably about 52 cars too many when operating in temperatures that cold, distributed power or not. I would ask my friends in Kazakhstan, where it is usually 30 below in winter, how they do it, but they usually don't run any train longer than 60 cars no matter what the temperature, given the length of their station and passing tracks.
The warning: Earlier in its run, before the crew took over this train on what turned out to be its, and their, final run, a previous crew had operated train 301-349. The train had "run away" from that prior crew on a downhill grade of 2.2 percent. That locomotive engineer was unable to limit the speed of the train on the descent through normal use of the train's air brakes and the locomotive's dynamic brakes. The engineer was only able to do one thing: stop the train by making an emergency application of the brakes.
After that nightmare experience, this crew, before being relieved from duty, met with a supervisor of the railroad. A "job briefing" or "de-briefing" was conducted, and a decison was made to set the retainer valves at the "high pressure" position on 75% of the cars. The high pressure setting on a retainer valve on a rail car means that when the train brakes are released, approximately 20 pounds (per square inch) of brake pressure will be maintained in the brake cylinders, if the brake system is working as intended.
You see, the retainer valves are affixed to the brake cylinder exhaust pipes. If the brake pressure is leaking out of the brake cylinders of the cars themselves, or out of the reservoirs for storing the air for the brakes, or at any location other than the "normal" route for exhausting the brake cylinder air, then setting the retainer valves to "block" the exhaust, and "hold" the air in the brake cylinders accomplishes..........nothing.
At least that's what I was taught back on my flatlander road.
The Transportation Safety Board (TSB)of Canada has not publicized what was discussed at this briefing; nor has it declared who made the decision to set the retainer valves.
The TSB of Canada did report that no hand brakes were applied to the cars in the train.
Say that again? A train has a runaway, requiring the crew to initiate an emergency application to bring the train to a stop....it's 30 below outside...the train may be sitting there for an hour or two at least...and no handbrakes are applied?
At this point, I want to ask my Canadian colleagues: "What is the problem you people have with handbrakes? You had a runaway at Lac Megantic that killed 47 people. Turns out no handbrakes were applied to the train cars. You have a runaway here, with every sign indicating that the efforts of the air brake system were insufficient to control the speed of the train, and you don't set the handbrakes?"
And I'd want to add, "Are you out of your minds?"
And the relief crew who showed up and took that train to their death-- did anyone tell them about any of this?
Was there a so-called job briefing that explained to these employees the circumstances of the previous runaway and the fact that there were no handbrakes applied on the train?
Did anyone think to tell them to secure the train with handbrakes because it was going to be necessary to recharge the brake system and then "walk" the application of the brakes to see if the air was leaking out of the brake cylinders causing the brakes to release rather than remain applied, because to relay a train, the new crew has to know the condition of the brakes?
Did anyone take the time to secure the train properly and, based on the results of the proper testing of the brakes, prepare to cut the train in half, calling out another crew with locomotives to take the second half of the train, even if that meant back-hauling to a repair location?
You don't need to be a detective to figure out what happened here. You don't need the Mounties to collect evidence.
This is bad business, literally. The railroad failed to manage the risk presented by the failure of the air brake system.
This never should have happened.
David Schanoes
January 30, 2020
You got the duty, Frost. Open that bag.
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