From: ahk@chinet.com

The disaster in Lac Magentic was caused by train MMA-002, operated by an
engineer without conductor, on Montreal, Maine, & Atlantic Railway running
away after being left unattended in Nantes. The train consist was 72 tank
cars and a buffer car (which protects the engine crew from disaster caused
by dangerous goods). There were five locomotives in the engine consist,
with a VB car (special-purpose caboose) behind the lead locomotive with
equipment for locomotive remote control. The engineer applied hand brakes
on 7 cars in total and shut down trailing locomotives, including 2 equipped
with auto-start that are not required to be shut down for fuel conservation
purposes as they shut off on their own eventually. The hand brake test was
performed without releasing the independent brakes (parking brakes) on the
locomotives, but this was a downgrade and it's not entirely clear if this
was a rules violation. Nonetheless, with independent brakes applied, it
didn't produce an adequate test of hand brakes.

Point 16, if I'm understanding it correctly, indicates why the engineer
thought the hand brakes were holding the consist after he performed the
roll test. It's clear that despite the engineer's long experience, he
was never trained adequately in calculating the number of hand brakes to
set nor what constitutes an adequate test of hand brakes. On page 127,
the point is made that MM&A's use of single person train operation
implementation didn't include training in adequate train securement. The
engineer must perform the conductor's duties as well as his own, and
apparently securing the train falls more heavily on the conductor portion
of this job. There was no mention if he first hired on at CP as a conductor.

A few points of interest from the Lac Magentic report:

1) The fire department shut down of the locomotive was done under railroad
direction, a fact I'm very glad to hear. Never read that in any of the
local or foreign stories I read of the disaster. Both the fuel line
valve was closed, to stop the fire, and the electrical breakers were
opened, to prevent a spark from igniting fuel. Unfortunately, MMA sent
a track foreman who wouldn't have a locomotive operating background and
didn't tell him to start another locomotive to keep the compressor going
to maintain air pressure in the air brake system. Normally, a penalty
brake application (dumping the air in all brake cylinders in the entire
train) would have occurred, except that the reset safety control (RSC)
was improperly wired so that this would not happen.

2) The engineer was rules qualified and not violating hours of service.
Montreal, Maine & Atlantic Railway is ex-CP trackage; MM&A is the
second short line to own it. The engineer had hired on to CP in 1980,
so he had plenty of experience.

3) Railroad industry assumes train crews are capable of exerting 125 lbs
of force on the brake wheel, but tests reveal that 80 to 100 lbs of force
is more typical.

4) Applying hand brakes on the locomotive is not assumed to be capable
of holding in place any additional cars. A new FRA standard applicable to
locomotives placed in service after January 4, 2004, requires the hand
brake to be capable of holding the locomotive in place on a 3% grade, a
net braking ratio of 10%. Generally, locomotive hand brakes met this
standard anyway prior to the effective date.

5) Applying the locomotive's hand brakes doesn't typically apply all
brake shoes. 2 of 12 brake shoes is typical, the way this model GE locomotive
was designed.

6) MM&A, as former CP territory, continued to use CP's General Operating
Instructions. It also refers to MM&A's General Special Instructions (GSIs)
and Safety Rules, without clarifying that these are additional documents
to those taken from CP.

7) Applicable number of handbrakes to apply uses a 10% of the number of
cars in the consist (72 in this case) plus 2. Setting hand brakes on the
locomotives counts toward the minimum. Hand brakes are required to be set
on the locomotive. Under this formula, 9 were to be set.

8) The grade at Nantes, where the train was parked, is .92%. From the
summary of rules given, assuming the consist holds for the hand brake test,
it doesn't appear that there was a requirement to set more than 9. However,
with 13 PSI automatic brake application to stop the train, 15 to 20
hand brakes should have been set, and without any air brakes, 18 to 26
air brakes should have been set. Interestingly, because of the wear on
the brake shoes on the locomotives' brakes, the engineer would have needed
to set between 12 and 18 brakes if just done on the cars.

9) Emergency brakes are applied with a complete dump of air. However, when
the air bleeds off slowly, and gets below 40 PSI, an emergency brake
application is no longer possible.

10) It took about an hour before the brake pressure fell to the point at which
the independent brakes (parking brakes) in the locomotive no longer held.

11) The sense and braking unit (SBU), a device connected to the rear of
the train attached to the brake line that can apply emergency brakes,
wasn't sufficient to apply emergency brakes in trains longer than 5
cars. By the time the device noted that the train had started to move,
brake pressure had dropped to 29 PSI.

12) In a test train with engine shut off, it took 1 hr 35 minutes before
air pressure dropped to 27 PSI, which is the pressure at which the train
started to roll. But the train's locomotive took 1 hr 6 minutes to drop
pressure to 27 PSI. Not ideal but not outrageous given the age of the parts.

13) The quick release brake (QRB) valve on the second locomotive in the
four locomotive engine consist failed. Typically, on a locomotive so
equipped, it opens to dump the air in the cylinder when the hand brake
is tightened when opened with the brake chain. The valve was worn and
damaged and, er, repaired in a non- standard manner (not explained). Unless
the air in the cylinder is dumped, the shoe isn't applied with the hand
brake. MM&A issued an instruction specific to these locomotives that the
crew member must listen for the air to be exhausted, otherwise the valve
must be operated manually, but the engineer wasn't aware of the memo.

14) Brake shoe testing of the locomotives indicated that some were worn to
through the lining to the backing plate. They can tell from wheel blueing
and lining wear that the independent brakes (parking brakes) had been
applying most of the braking force for the train. Finally, not all the
wheels showed full tread blueing nor brake shoe lining wear, indicating
that the hand brakes had not been, or could not be, applied securely.

15) 146,700 pounds retarding brake force was required to keep the
consist parked. The calculations are on page 27 if you care to read them.

16) Hand brakes are to be applied after full release of air brakes,
except that it's not possible to fully release air brakes when the train
is stopped on a grade. So the 13 PSI automatic brake application at
Nantes (where the consist was parked) resulted in hand brake forces
40% higher than without air brakes. Page 38

17) Reset safety controls (RSCs) are features of locomotives manufactured
since 1986. The 3 pre-1986 GE locomotives were retrofitted with them
by a previous owner. RSCs incorporate the dead man's switch feature,
but also apply a penalty brake application in the event of opening the
breaker or shutting off the main electrical power. There's no requirement
that the penalty brake application function work with power loss, so
it's not required that this be tested for in the shop. Wiring of this
device was inconsistent among the three locomotives and the penalty brake
application didn't necessarily occur as it was supposed to. In fact, 5
other GE locomotives owned by MM&A had inconsistent wiring problems. In
one of the locomotives in the engine consist, RSC was wired directly to
the battery and therefore remained powered even though the main electrical
power was shut off.

Now, penalty brake application dumps the air in the cylinder, but I don't
understand how long the brake shoe is held in place. It's not an
indefinite application of brake force like a properly set hand brake, right?

18) Pages 29-31 and 113 discuss the serious problems with the lead
locomotive and temporary and improper maintenance peformed on it. The
temporary repairs were explained by MM&A having no spare locomotives and
an increase in traffic due to oil trains. Gee, you'd think they could
have rented one so they'd have had time to perform proper maintenance. The
locomotive remained in service despite problems being reported. The most
serious maintenance issue was the shop "repairing" an oil leak at a cam
bearing bore by overtightening the mounting bolt. After the disaster,
testing revealed that the bearing had fractured.

--- SoupGate/W32 v1.03
 * Origin: LiveWire BBS -=*=- UseNet FTN Gateway (1:2320/1)