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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