From: ahk@chinet.com

Wolfgang Keller  wrote:

>> The following is excerpted from the report, pages 1 and 2:
>> [[ At around 2250, the train arrived at Nantes, was brought
>> to a stop using the automatic brakes, and was parked for the
>> night on a descending grade on the main track.

>You never do that.

>*NEVER*.

>*N-E-V-E-R*.

>No catch points, descending track - that means *asking* for disaster.

>No, in fact it means *begging* for disaster. On your knees.

>What criminally irresponsible moron allowed that kind of operating
>procedure?

Uh, what are you talking about? Railroads aren't perfectly level unless
perfectly graded across a glaciated plain, and nothing's ever perfect.
The town itself was at the bottom of the dip, but you're not going to
park a consist in town blocking grade crossings.

>Examples for parked rail vehicles, whether individual or groups
>of waggons, locomotives or entire trainsets that "run away on their own"
>are *legion*. Even vehicles with automatic spring-applied parking
>brakes, such as EMUs do it all the time. It happens everywhere (where
>there are railways with sloped tracks) each and every year.

>Why do they *refuse* to learn?

I've just never heard of trainsets running away on their own with a
sufficient number of hand brakes set after the engineer correctly tested
that a sufficient number of hand brakes were set.

I had no idea EMUs had no hand brakes.

>>Critical factor that caused the disaster:
>>AFTER CONDUCTING THE "RELEASE TEST" (even though it was not
>>properly tested), THE ENGINEMAN LEFT THE AUTOMATIC AIR BRAKE
>>(TRAIN AIR BRAKES) IN THE "RELEASE" POSITION.
>>HE NEVER RE-APPLIED THE TRAIN AIR BRAKES USING THE AUTOMATIC
>>BRAKE VALVE BEFORE HE LEFT THE TRAIN.
>>(I will delve more into this below)

>That's not a *root* cause analysis. That barely scratches at the bark
>of the fault tree.

>The critical factor was *way* before that.

>The point of *safe* operating procedures is exactly to *avoid* such
>situations where simple trivial mistakes by individual operators can
>cause havoc.

>You *never* make the operator in the field the *last* safety barrier.

The engineer's critical mistake wasn't simple nor trivial. He didn't understand
how to test that hand brakes held the consist because he didn't know he had
to release the independent brakes.

The operating employee is the first and last safety defense, always.

>Again: That's what safe operating procedures are there for. For
>providing safety barriers. That are *independent* (as far as
>possible) from simple mistakes by operators.

I agree with this.

>While the actually responsible pondscum will take their golden
>parachute and get away with it.

A golden parachute from a bankrupt company? Uh, no.

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