NTSB Report…East Palestine

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An initial early report is out by the NTSB about the train derailment in East Palestine, Ohio.  Was it caused by deregulation as many bobbleheads in the media have suggested?  Was it caused by a failure to implement common sense safety regulations?  Was it simply an unavoidable accident caused by a perfect storm of railcar failures that could not have been anticipated?

The answer to all of these questions is a resounding “No.”  The data was there for the train to be stopped and inspected BEFORE the catastrophic failure occurred.

The actual sequence of events at the moments of failure have been determined.  From the NTSB:

Train 32N was operating with a dynamic brake application as the train passed a wayside defect detector on the east side of Palestine, Ohio, at milepost (MP) 49.81.  The wayside defect detector, or hot bearing detector (HBD), transmitted a critical audible alarm message instructing the crew to slow and stop the train to inspect a hot axle. The train engineer increased the dynamic brake application to further slow and stop the train. During this deceleration, an automatic emergency brake application initiated, and train 32N came to a stop.

As it should be, this is a neutral and non-judgmental description of some 38 railcars derailing with an additional 12 railcars damaged by subsequent fires.  Without getting into the whys, it tells what happened.  This summary tells us nothing about the causes of this derailment.

Is there information in the report that allows us to begin to ascertain the likely cause(s) of this environmental disaster?  The answer is an unqualified “yes.”

This is an environmental disaster on the potential order of Chernobyl or Love Canal.  While the government elites are saying that the water has been tested and is safe, this is now.  The town gets its water from several wells.  How long will it be before the hazardous chemicals that were spilled make their way deep enough into the groundwater to be detected?  What will it take to remediate that damage which is coming as certain as the sun rising in the east?  Video clips have emerged that show that animals and fish appeared to have died as a direct result of this accident.

Back to the potential cause(s) of this disaster.

Let’s talk about dynamic braking.  A very simple explanation is that the electric motor in the diesel-electric locomotive is used to slow the train.  This may be used on a downgrade to control the train’s speed.  On the surface that appears to be what was going on.  The train was within speed limits for that section of track.  The train was moving at 47 mph where the speed limit was 50 mph.

When the alarm was received about the “hot box” problem that the train had, the engineer then increased the dynamic braking so that the train could be stopped and the “hot box” examined.  Shortly after this, an automatic emergency braking occurred.

Automatic emergency braking can occur in two ways.  One can be initiated by the engineer.  The event data recorder (similar to the black box on airplanes) should show if that happened.  The other method where this can happen is for the air line that powers the emergency system to be breached.  This happens during a derailment.  However, this is not the only way that the air line can be breached.  Anything that compromises the integrity of the air line and causes a loss of air pressure can do this.

Was there another possible way that the line could have been breached?  As it turns out, the NTSB report provides a possibility.

NTSB investigators identified and examined the first railcar to derail, the 23rd railcar in the consist. Surveillance video from a local residence showed what appeared to be a wheel bearing in the final stage of overheat failure moments before the derailment.

Could this have destroyed the integrity of the air line?   Absolutely!  The wheelset was on fire as the video shows.  The railcar in question was carrying plastic pellets which also caught fire.  Further investigation by the NTSB should be able to determine if that happened.

Did the initiation of an automatic emergency braking cause the accident?  The answer here is a tentative no. The most likely cause was an overheat failure within the wheelset that was on fire.  The axle bearing loses its ability to function properly and one or both wheels on that axle jump and/or destroy the integrity of the rail it is traveling on.

Once this happens, the immutable laws of physics around momentum take over.  Regardless of how much braking force is applied, it takes a long time to stop a train due to the ridiculous amount of momentum the train as a whole carries.  There is no such thing as stopping a train that is traveling over 40 mph on a dime.

Now that the NTSB has provided us with a good idea of what happened, is there any information about whether this catastrophe could have been avoided?  As it turns out, the facts within the NTSB report do provide some insights into this.

Train 32N passed three HBD systems on its trip before the derailment. At MP 79.9, the suspect bearing from the 23rd car had a recorded temperature of 38°F above ambient temperature. When train 32N passed the next HBD, at MP 69.01, the bearing’s recorded temperature was 103°F above ambient. The third HBD, at MP 49.81, recorded the suspect bearing’s temperature at 253°F above ambient.

NS has established the following HBD alarm thresholds (above ambient temperature) and criteria for bearings:
• Between 170°F and 200°F, warm bearing (non-critical); stop and inspect
• A difference between bearings on the same axle greater than or equal to 115°F (non-critical); stop and inspect
• Greater than 200°F (critical); set out railcar

HBD is a “hot box” detector.  The first indication of possible trouble (MP79.9) showed a temperature 38F above ambient temperature.  12 to 14 minutes later the next sensor showed 103F above ambient.  That means that the temperature for the problem bearing was rising at the rate of roughly 5 degrees per minute.  It is not yet at the “stop and inspect” limit.  However, it will be in two to three minutes.  The next sensor was 25 minutes away.

Karl Denninger notes:

Anyone with a brain in their head had to know that if you are at 38F over ambient and ten miles later you’re more than 100F over ambient you will exceed the “stop and inspect threshold” well before you reach the next detector in 20 more miles, and if the failure is progressive, and most failures are, you will be well over the critical threshold and on the verge of a catastrophic failure by the time you get there.

You don’t need to be a rocket scientist to know this — you simply need to be competent to operate dangerous machinery with known margins which you must not exceed for said machinery to remain safe and know that there is a progressive failure showing up in the data.

That’s exactly what happened and nothing more than basic arithmetic — sixth grade material here folks — was required for anyone and everyone who saw that data to know that continuing to operate that train was dangerous and quite likely to lead to a disastrous failure.

This leads to some obvious questions.

Was the crew alerted to the first two sensor readings?

If no alerts were issued, then whoever designed the system is incompetent.  This kind of information is critical to the safe operation of the train.  Withholding this data from the crew, not alerting the crew to a potential progressive failure going on, would demonstrate a callous disregard for the safety of the crew and the public.  Speaking of incompetence, has the doofus who is in charge of the Department of Transportation even asked such a question yet?

If the crew was alerted to the first two readings, the next question has to be why did they ignore the fact that a potential progressive failure was going on?  Whoever made that call is not competent to be anywhere near a locomotive.

Denninger notes:

The entire point of a system like this is to detect incipient problems with plenty of time to take corrective action.  The equipment was functional but no equipment can do anything about HUMAN STUPIDITY whether in what the equipment communicates due to its design or what people do with the information if it is communicated.  Damn written policy and “limits” to Hades; if you, as an operating engineer with two firing neurons in your head, observe a condition that any reasonable person who has an IQ sufficient to be trusted with dangerous machinery is nearly certain to degrade beyond safe limits based on the data you have before you can get to the next confirmatory signaling device YOU STOP NOW AND FIND OUT WHAT IS GOING ON.

If it turns out that alerts were not acted on, then the corporate culture at NS needs to be examined.  Has their commitment to diversity overridden the requirement for competence?  Is this another example of sacrificing safety on the altar of diversity, inclusion and equity?  Or are rulebook strictures overriding common sense?

One thing is certain here.  Despite the bobbleheads in the media pointing fingers at PDJT, no regulation on braking had anything to do with this mess.  It is looking more and more like operator error either in the system design or in the operation of the train.