From: nilknocgeo@earthlink.net

"Wolfgang Keller"  wrote in message
news:20140822133415.04d574effde85238ba29b010@gmx.net...
>> 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?
>
> 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?
>
>> 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 question is:
>> Why didn't he re-apply them?
>
> Because humans do make mistakes. Especially at the end of their working
> shift, when they're tired and exhausted.
>
> 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.
>
>> But again, a terrible mistake.
>
> Disaster manufactured by managers.
>
> By eliminating safety barriers.
>
> As *always*.
>
> And the poor guy in the field will not only be left with that huge load
> of guilt on his conscience, but will also get slaughetered as a
> scapegoat in court.
>
> While the actually responsible pondscum will take their golden
> parachute and get away with it.
>
> Sincerely,
>
> Wolfgang
>
> Reliability and safety engineer by education.


Well Canada did the following:
According to some press reports:

Quebec authorities have charged the train driver and two rail officials with
criminal negligence.

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