From: feliphil@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.   
      
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