Safety management systems generate an awful lot of “proof of activity”, much of it paperwork, that may not connect to actual attention or action towards correction of problems. As SMS requirements are ramped up, the work tends to get hived off to specialists in the office, which may actually disconnect the effort from the hands-on workers and managers who are central to safety. The terminology and concepts of safety analysis may look good on paper but do not necessarily resonate with anyone in authority. Certainly, it’s clear from this report that CP’s use of SMS didn’t trigger corrective action on grain train air brake issues, despite these being quite visible. In this case the elephant in the room was being fed and groomed without anyone pointing to it..
It’s inevitable that corporations will lawyer up after an incident, but I agree that CP set a new low bar for denial and naysaying, and perhaps avoiding truthfulness, in a situation where by any ethical standard the emphasis should be on ensuring that the truth does out.
What was even more damning to me was the clear evidence that the trains were being operated in unacceptable condition
- when after this event CP began using “cold wheel” measurements to detect grain cars with ineffective brakes, they found 5,000 cars needing repair (page 13)…. that’s a huge number, and suggests that the condition of the fleet as a whole was poor
- the forensic examination of the wreckage established that too many cars had poor or inoperative brakes in relation to regulatory and railroad standards
- the report comments that previous incidents of poor braking condition and performance of the grain car fleet was widely known among operating employees, yet apparently overlooked by CP management
- the Engineer who died had a similar experience on their previous trip, and was in the process of reporting same when this incident happened
The investigation uncovered a number of other things that can be constructively improved (eg engineers’ air flow instrumentation, configuration of braking on DPU locomotives, training and qualifications, operating procedures) - but what’s scary to me is just how tolerant the culture was of a very apparent danger.
- Paul