derailment elimination in today’s
TRANSCRIPT
Copyright © 2021
Essential Strategies for
Derailment Elimination in Today’s
PSR Environment - Part 2.
Wolf Railway Consulting
2838 Washington Street
Avondale Estates, Georgia
30002
404-600-2300
www.wolfrailway.com
William Hay Lecture
Presented by:
Gary P. Wolf
12+ Tactical Strategies
to Reach a Goal of
1.0/MTM
1
Copyright © 20212
First…A Memorial Day thank you for the brave men
and women of America who gave their lives for our
country…
Take time to remember their sacrifice this weekend
Omaha Beach Cemetery Normandy
Copyright © 2021
Breaking News!!!
• Since Part 1 of this William Hay Lecture (April 9),
there have been some recent developments
concerning the impact of PSR on Freight Railroading
✓Congressman DeFazio has requested a GAO
Study of the impact of PSR on rail shippers,
employees, and Safety
✓Grady Cothen, retired FRA Deputy Assc.
Administrator for Safety Standards, has authored
a white paper entitled “Management of In-Train
Forces – Challenges and Directions” (See
Railway Age Website to download)3
Copyright © 20214
Strategic Plan – Where we
are going, a goal, a
destination.
i.e., 1.0 Derailments/MTM
Tactical Plan/Strategies –
How to get there…
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Train Accident Rate per Million Train Miles
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GOAL 1.0
Source FRA Accident
Database
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2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Ex
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Nu
mb
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of
De
rail
me
nts
Annual Human Factor Derailments and Expenses
Number of Derailments Expense (millions)
Source FRA Accident
Database
Human Factor Derailments
6
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12 Tactical Strategies
1.Develop a Corporate Focus
2.Develop a network of integrated and
automated inspection/detection
systems
3.Leverage Big Data
4. Insure Correct Curve Elevations
5.Manage Wheel/Rail Interface
6.Develop an effective rail lubrication
program
Copyright © 20218
12 Tactical Strategies con’t.
7. Eliminate Rail Cant
8. Eliminate tight side bearings and excessive
friction wedge rise from your cars/wagons
9. Manage CWR and Rail Neutral
Temperature (RNT)
10.Develop train make-up rules and
strategies
11.Perform Root Cause Analysis on Human
failures; Change descriptions into causes.
12.Increased focus on drainage/water
management
13.BONUS! – Better turnout inspections
Copyright © 20219
Disclaimer:
These recommended strategies are not to imply that these are all
you should do. Many other strategies should and must be
implemented as well. Every rail system must assess what is
needed and prioritize those strategies for their particular railroad.
Although certain products or companies may be mentioned in this
paper, their mention does not imply an endorsement or
recommendation for these products, or that these products are
suitable for your railroad.
Copyright © 202111
A Corporate Focus on
Derailment Prevention
• Must start from top of organization
• Organization must be committed to the
process; must be imbedded in the corporate
culture
• If it’s everybody's responsibility it will end up
being nobody’s responsibility
• An individual must own the process and must
be accountable for success.
Copyright © 202112
Corporate Focus
• Corporate ownership of Derailment Prevention
• Need a champion, a mentor, to coordinate efforts and take ownership within the corporation. Director level or higher to establish visibility/standing within organization.
• Neutral reporting relationship to avoid bias
• Establish accountability
• Establish Mission, Goals, Objectives, and Strategy
• Multidisciplinary derailment prevention TEAM(S) (NOT committees).
• Divisional field teams working in conjunction with corporate
• Engineering, Mechanical, Operations, Safety, Signal, others
• Revolving leadership
• Statistical Analysis
• “if you can’t measure it…you can’t manage it”
• FRA reportable and Non-reportable incidents
• Must assign accurate cost of failure taking into account all costs
Copyright © 202113
Accurate cause finding prevents a
recurrence of another derailment on
that section of track, or with that
particular vehicle or vehicle type, or
with that particular crew.
“Those who cannot remember the past are
condemned to repeat it“ George Santayana
Derailment Prevention
Starts with Accurate
Cause Finding
Copyright © 202114
Accurate Derailment
Cause Finding• Unbiased, Multiple Disciplinary Approach
• Must be done in a timely manner
• Objective and data driven
• Track Measurements, Car/Truck Inspection
• Event recorder data and train handling analysis
• Metallurgical analysis (in some cases)
• Simulation analysis (TOS, VAMPIRE, SIMPACK, etc.)
• Targeted Corrective Actions
• Cost Effective
• Within Corporate capabilities
• Check for unattended consequences
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Cause Finding Caveats
• Most derailments have multiple causation; Rarely
one single cause
• Must determine primary or root cause
• Must also address all contributory causes
• May not find a direct violation of AAR, FRA/TC, or
Operating Rules
• Standards don’t cover everything
• Standards don’t always take into account multiple deviations
between and within standards
• You may have discovered the need for a new standard or
rule; standards and rules need periodic updating
• The greater the number of deviations from standards
that you tolerate, the higher the probability of a
derailment
Copyright © 2021
Failure to Identify Correct Cause
• Departmental Biases
• Lack of systematic/analytical approach;
sloppy investigation
• Not getting the data and facts
• Lack of Motivation; “nobody cares”
• Poor communication/cooperation
• Intra-departmental
• Cross-departmental
• Rushing; not enough time; being rushed
• Looking for obvious cause(s)16
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The Problem …
▪ Many derailments and accidents are
“Organizational” incidents, yet we are
not drilling down to the root cause level
to adequately determine all the causative
issues.
▪ We are stopping at the individual level
(someone to blame), or only identifying
symptoms/conditions (e.g., wide gage).
▪ In order to reduce risk, all causative
factors must be identified and corrective
action taken.17
Copyright © 2021
Basic Question in all accidents – How
were the defenses breached?
• Three factors implicated:
• Human performance (rules)
• Technical systems (infrastructure/vehicles)
• Organizational Issues (culture, budgets)
• All three factors governed by 2 processes central to
all organizations
• Production (PSR)
• Protection (Safety/Inspections/Rules)
18
Copyright © 2021
Trends in Derailment
Cause Finding• Many of the easy to understand causes have been
eliminated
• As wheel loads and speeds increase, causes have become more complex, often requiring understanding of wheel/rail mechanisms
• With longer trains (PSR), Train Makeup/Handling has become a much bigger issue to take into account
• The higher stress state in the rail environment has mandated a better understanding of fatigue mechanisms (materials and humans)
• Due to downsizing, privatization, attrition, and retirements, the industry knowledge level has declined considerably
• Better training and tools are required for modern derailment investigation
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Detection Strategies to Reduce
Derailments
• Modern detection technology, coupled with communications infrastructure and data analysis, can detect incipient conditions before they become derailments
• Wayside Systems to monitor rolling stock
• On-board systems to monitor vehicle conditions
• On-track systems to detect track faults
• Locomotive mounted systems to prevent collisions, speed limit violations, poor train handling and to monitor operations
21
Copyright © 202122
Track and Infrastructure
Monitoring• Legacy Systems
• Ultrasonic Rail Flaw and Joint Flaw detection
• Track geometry measurement
• Gage Restraint Measurement Systems (GRMS)
• Slide Detectors/ Seismic Detectors
• Rail Profile and Rail Wear
• Rail Friction Measurements (Tribometers)
• Bridge Monitoring
• Ground Penetrating Radar (GPR)
• New and Developing Technologies
• Automated crosstie inspection and grading
• Vision system to inspect fasteners, bolts, plates, Rail Seat Abrasion, Joint Bars
• Track Deflection Measurement; Track Stiffness (MRail)
• Rail Surface conditions (RCF and micro-cracks)
• Rail Neutral Temperature (RNT) Monitoring
Copyright © 202125
Multi Sensor from Vortok
Robotic Track Geometry from
RailPod
Rohmann Eddy Current Crack
Detection
Emerging
TechnologiesAutonomous TGC from
Tetra Tech
Copyright © 202126
Wayside Detection &
Inspection• Legacy Systems
• Hot box (Hot Bearing) detectors; Temperature Trending
• Dragging equipment
• High and wide clearances
• Wheel Impact Load Detection (WILD)
• Truck Performance Detectors (TPD)
• Truck Hunting Detectors
• Wheel Profile; Wheel Defect
• Hot/Cold Wheel; Brake Defects
• Low Air hose
• New and Developing Technologies
• Wedge Rise
• Brake shoe thickness
• Coupler Securement
• Safety Appliances (ladders, grab irons, platforms)
• Ultrasonic and Acoustic Hot Box detectors
Copyright © 202128
Matzan Reliability Solutions
Ultrasonic Signal
Coupler View
Wedge/Spring View Ladder View
Emerging
Technologies
Emerging
Technologies
UT Wheel Inspection
Copyright © 202129
On-Board Locomotive
Monitoring and Detection
Technologies
• Event recorders
• On-board video cameras
• Condition Monitoring of locomotive performance
• Vision Systems
• Positive Train Control
• Communications Based Train Control
• Need greater leverage of these systems; build out the platform for better payback
Copyright © 202131
And, another important technology building block for
autonomous operation of trains.
Copyright © 202133
Vehicle Remote Monitoring
Systems
•Load Status Sensor•Hatch Securement Sensor•Temperature Sensor•Brake Sensor•Wheel and Bearing Sensor
Copyright © 202134
Conclusions - Detectors
• There have been significant advancements in automated detection,
inspection and monitoring systems in the past 15 years.
• New and emerging technologies need further testing and investment to
prove benefits. Also, need support of regulatory authorities (Incentives).
• These devices eliminate subjectivity of human inspection, and improve
day to day reliability of inspection. Can change “finders” into “fixers”.
• Next challenge to increase the deployment of these devices is to justify
capital expenditure through relief from costly mandated human inspection
of track and equipment (Regulations).
• Using automated detection data, rail industry can move from reactive
maintenance to preventive/predictive maintenance.
• Another challenge facing every railroad is “what to do with all the data?”
Need advances in data warehousing and data mining to extract the
maximum value from the data. Need automated algorithms to interpret
and analyze data. Can’t have humans poring thru terabytes of data.
Copyright © 202135
3. Leverage Big Data
(Industry 4.0 and the I of T)
The connectivity and
automation of industrial
processes
Copyright © 202136
Wheel Wear
Ballast
Section
Rail Wear
Engine Hours Fuel Consumption
Wedge Rise
Geometry
Rail
Temperature
I of T
Rail Flaws
L/V Forces
Oil PressureLocation
Rail Stress
Bearing
Temperature
Crew Performance
Copyright © 2021
Big Data, the 3 V’s
(We are in the Zettabyte era,
1021 bytes , or one trillion gigabytes)
•Volume - how much?
•Velocity- how fast is it coming in?
•Variety - how many types of data?
37
Copyright © 2021
Benefits of Big Data
•More data; more complete
information
•Less standard deviation of data
•Greater confidence in answers;
higher R2
•But data itself has zero value unless it
can be used to create value
38
Copyright © 2021
Big Data moves us from fixers, to
preventers, to predictors, to
genies
• Reactive maintenance – fix what’s broken
(WILD)
• Preventive – use data to prevent future failure
(Bearing Temperature Trending)
• Predictive – when will the bearing fail based
on mileage, tonnage, wheel profile,
temperature?
• Prescriptive – AI, machine learning tells us
how to fix the problem to prevent failures.39
Copyright © 2021
To make it happen...Data Analytics
• Need to in-source or out-source data analytics
function
• Data Analytics is the process of
sifting/analyzing raw data to reach statistically
valid conclusions
✓Monte Carlo (probabilistic based)
simulation
✓Regression (linear/nonlinear)
✓Multivariate Adaptive Regression Splines
(MARS)
✓Time series40
Copyright © 2021
Data Analytics Warning
• Make sure your sensors/systems are producing
reliable data (Car tags, TGC, Rail flaw)
• Perform statistical process control on data values
• You will need data governance (person or group):
✓Quality
✓Privacy
✓Security
✓Retention (data warehousing - cloud vs. server)
✓Trustworthiness of data
41
And here’s an idea – let’s use Data Analytics on Human
Factor Derailments.
Copyright © 2021
Curve Elevation Issues
• Over-elevated Curves
• Legacy from prior operating conditions
before longer, slower trains
• Legacy from Prior Owners
• Mixture of Passenger/Freight
• Under-Elevated Curves
• Bottom Line: Comprehensive review of curve
elevation should be an on-going process in
light of changes in train operations (fewer,
longer trains)
44
Copyright © 2021
Superelevation Derailment
Issues
• Excessive elevation places adverse vertical
forces on the low rail of curves, which can result
in broken rails, broken joints, low rail rollover,
and wheel climb on high rail
• Many curves in North America are currently over-
elevated given operating train speeds. Short
lines are especially vulnerable to this condition.
• When operating in over-elevated curves,
derailment risk increases when encountering
significant track perturbations which may be
FRA/TC compliant.
45
Copyright © 202146
Running Slower than
Balance Speed for Curve
Wheel
Climb on
High RailLow Rail
Rollover
Over Elevated Equilibrium
Copyright © 2021
Objective: Elevate majority of
curves at 1”-2” Unbalance• Action Items:
• Review actual train speeds on territory
• Speed tape analysis
• Train riding and reporting
• Simulation analysis
• Try to eliminate unnecessary speed changes
• Create prioritized list of improper elevations
• Develop plan to re-elevate curves
• Look to change speed limits for short term
solution if necessary
Tip: Check elevation run-off rates in spirals
47
Copyright © 202148
5. Manage Wheel/Rail
Interface
A lot goes on right here in
a very confined area
- Steering
- Traction
- Braking
- Support
Your management of the
wheel rail interface is either
conducive to good
performance and long asset
life, or short asset life and
derailment.
~ 0.5 in2
Copyright © 2021
Higher Axle loads, higher
wheel/rail contact stresses,
requirements for higher
adhesion, and at times higher
drawbar forces, mandate a
rigorous, more proactive
approach, to managing the
wheel/rail interface.
49
Copyright © 202150
Management of Wheel/Rail
Interface – Why?• Surface Condition of the Rail Causing RCF
• Grinding to eliminate development of RCF (Prevent Broken Rails)
• Profile Shape of the Rail (Rail Grinding)
• Minimize contact stresses
• Maximize wheelset steering
• Minimize probability of wheel climb
• Minimize probability of rail rollover
• Profile Shape of the Wheel (Wheel profiling)
• Minimize contact stress and development of shells
• Minimize high speed instability (prevent hunting)
• Maximize steering in curves (prevent gage widening)
Copyright © 2021
Wheel & Rail Profile Issues
• Rail Profiles
• Wheel Climb
• Wheelset Steering
• Rail Rollover
• Contact Stresses (RCF)
• Wheel Profiles
• Wheel climb
• High Speed stability
• Wheelset Steering
• Contact Stress (shells)
51
Copyright © 2021
Detail Fracture leading from large shell on gage corner.
In service failure. Note batter on both side of break.
53
Copyright © 2021
LOW Rail in Curve
Spalls develop due
to excessive contact
stress between the
false flange of
hollow worn wheels
operating below
balance speed on
track with wide gage.
54
Copyright © 202155
Profile shape of High and
Low Rail has significant
influence on gage
widening and rail rollover
derailments
Copyright © 202156
Significant Gage Face Wear Moves Vertical load closer
to the field side, Reducing Resistance to Rollover
New Moderate Severe
Levels of Rail Wear and Effect on B/H (L/V) Ratio for Rollover
.65 B/H .53 B/H .42 B/H
Copyright © 2021
Base 2.75”
Height 6.8”
L/V = b/h
2.75”/6.8” = 0.40
Rail Rollover Potential with Severe Gage Face
Wear 57
Copyright © 2021
Low Rail Contact Stress Due to Wide Gage
and Running with Hollow Worn Wheel Profile
This Makes Low Rail Prone to Roll Out
58
B/h Ratio
2.5”/7.0”
L//V for rollover = 0.35
Copyright © 2021
Nadal’s Formula
L tan ( ) - µ
1 + µ tan ()V=
µ
Angle between
wheel and rail
Friction between
wheel and rail
59
Wheel climb is
dependent on
gage face angle
and friction
Copyright © 2021
Severe Hollow Wear
Hollow Worn Wheels
Are a reality in the
North American fleet
✓ They Hunt
✓ They don’t steer
✓ They cause RCF
Moderate Hollow Wear
60
Copyright © 2021
Wheel/Rail Contact Geometry
on High Rail of Curves
Conformal ContactModerate Two-Point
ContactSevere Two-Point
Contact
63
Good Steering OK Steering Poor Steering
Copyright © 2021
Conclusions – Wheel/Rail
• You need a wheel & rail profile measurement
system(s).
• Rail Grinding is essential
✓Removes RCF – Prevents broken rails
✓Maintain gage face angle >70º - Prevent wheel climb
✓Contour grinding to promote good steering (High + Low)
• Evaluate rail wear limits for defect growth, Nadal
(wheel climb), and B/H ratio (rollover)
• Wheel profiling harder to cost justify with interchange
fleets and AAR billing rules; Easy to cost justify with
captive fleets (transit, mining, commuter)
64
Copyright © 202165
Tip: Excellent
reference
source for
managing the
wheel rail
interface
Available from:
International Heavy Haul Association
www.IHHA.net
Copyright © 202166
Tip: Excellent
seminar for
learning about
managing the
wheel rail
interface
October 18-21 2021 Chicago
www.wheel-rail-seminars.com
Copyright © 2021
Lubrication and
Derailment Prevention
• Rail Lubrication/Friction Modification is
essential in today’s heavy haul environment
• Proper rail lubrication/friction modification is
important in lowering derailment risk:
• Proper gage face lubrication of high side of
curves reduces wheel climb potential
• Proper top of rail lubrication reduces gage
spreading forces and rail rollover potential
68
Copyright © 2021
Low Rail
High Rail
Coefficient of Friction for Good Performance
.35 - .40.15 -.30
Top Of Low Rail
Gage Face of Rail
69
Copyright © 2021
Top or Rail Lubrication
eliminates Exceedances
greater than 15 Kips
Source: Rail Sciences Test Data71
Copyright © 2021
Top of Rail Friction Control
(TOR) – Why???
✓Reduce Curving Forces
✓Reduce Wheel/Rail Noise
✓Reduce Rail Wear
✓Reduce Tie and Fastener Wear
✓Reduce Wheel Wear
✓Reduce Energy Consumption
✓Reduce Derailment Potential
72
Copyright © 2021
Lubricants vs. Friction Modifiers
▪ Lubricants
▪ Greases, Polymers, Petroleum (oils)
▪ Effectiveness depends on amount of lubricant present. Hard to control application rates.
▪ Can act as a hydraulic fluid and open up surface cracks
▪ Friction Modifiers
▪ Engineered solids
▪ Deposited in water based medium and evaporates as film
▪ Constant COF over life of film; easy to control
▪ Does not act like a hydraulic fluid73
Copyright © 2021
Develop optimum lubrication
strategy for key locations
• Determine critical locations
• Severe curves (>5 degrees)
• Heavy grades
• Determine best delivery method
• Train traffic density
• Hy-rail access
• Cost/benefit tradeoff
• Type of friction modifier
• Warnings
• Watch for high tractive/braking effort areas
• Areas of heavy shelling75
Copyright © 202177
Canted Rail
• Canted Rail is a leading root cause of many
wide gage and rail rollover derailments
• Rail Cant causes adverse wheel/rail contact
leading to aggressive development of Rolling
Contact Fatigue (RCF)
• Rail Cant is not regulated in North America
• Most railroads are starting to measure rail
cant on their Geometry Cars.
Copyright © 2021
L/V (B/H) = 2.5/6.75 = .37
Rail Rollover L/V Reduced
2.5”
Differential Plate Cutting
L
V
79
Copyright © 202181
Remediation of Rail Cant• Tie Replacement
• Caution: spot tie replacement can lead
to problems in curve with significant rail
cant
• Tie Adzing to renew tie surface
• Shims can be used as temporary repair
• Recommend epoxy plugging compounds
in spike holes
• Epoxy treatments for concrete ties
• Grind rail after restoring rail cant
Copyright © 202182
8. Eliminate Tight Side
Bearings and Excessive
Friction Wedge Rise on all
Vehicles
Copyright © 2021
Barber Gage
Ride Control
Gage
“Moustache” gages to check for
excessive wedge rise when car is on
repair track85
Copyright © 2021
Summary - Importance of
Friction Wedges
• Harmonic rock/roll
• Speeds of 15-25 MPH
• Vertical Bounce
• Speeds > 55 MPH typically
• High Speed Hunting
• Speeds > 55 MPH typically
• Curve Negotiation
• All Speed Ranges (0 - 60 MPH)86
Copyright © 2021
Truck Side
Bearings• Standard Roller
• Steel Block
• Constant Contact, or Resilient
87
Copyright © 2021
First Problem with Tight Side
Bearing Clearance
• Causes Pre-Mature Contact in Entry Spiral
between car body and side bearing roller
• Bolster trying to rotate (steer) at this Point
• Slip/Stick Contact at Side Bearing roller has
potential to cause Stiff Bolster
• CCSB set up heights less than 4 7/8” can also
significantly increase turning resistance
88
Increases L
Copyright © 2021
Second Problem with Tight
Side Bearing Clearance
• Tight Side Bearings (especially across diagonals) Causes Pre-Mature and rapid vertical unloading of opposite corner of car
• Unloading of vertical weight at corner of car results in higher L/V ratio
• Increases probability of wheel climb due to track twist, crosslevel deviation, or spiral entry/exit
89
Decreases V
Copyright © 2021
Summary - Side Bearings
• Too Tight (or insufficient CCSB set-up
height)
• Stiff/Binding Truck; poor curving
• Vertical Wheel Unloading when
encountering marginal track twist
• Results in Wheel Climb derailments
• Too Much Clearance
• Harmonic Rocking Increased
90
Copyright © 202191
9. Manage CWR and Rail
Neutral Temperature
(RNT)
(Tip: Most Track Buckles occur in the
Winter Months of January and February)
What did he just
say?????
Copyright © 202192
Proper Control of Rail Neutral
Temperature (RNT). Also Called Stress
Free Temperature (SFT)
• CWR Rail may be laid at the correct neutral
temperature, but over every seasonal change, the
RNT is gradually ratcheted downward.
• Lowered RNT is a major root cause of track buckle
derailments
• Areas subjected to large seasonal temperature
changes most susceptible, e.g., Upper Midwest in
North America where it might be 100°F (38C) in
summer and -30°F (-34C) in winter.
• Keeping RNT at proper level is a continual battle that
must be fought annually. You cannot become
complacent!
Copyright © 202196
Symptoms of track
needing RNT adjustment
• Recent rail replacement plugs, especially during cold
months
• Recent Curve Patch rail relay (even if just one rail)
• Recent tamping to correct lateral or vertical
perturbations
• Areas of poor ballast section, cribs and shoulders
• Nervous Rail, rail crowding plates and canting in/out
• Inward movement in “staked” curves; formation of
ballast pockets
• Tie Skewing, anchor movement, tie bunching
Copyright © 202197
Tamping of track to correct vertical profile
deviations can have the effect of adding rail
Copyright © 202198
Monitoring of RNT
• Visual inspection of “staked” curves;
nervous rail crowding plates and
canting
• VERSE Testing
• Only method proven to be accurate
with +/- 1 degree
• Recent technology to measure rail
strain
Copyright © 2021100
MultiSensor™
➢ Vertical Shear Strain
➢ Horizontal Strain
➢ Core Temperature
➢ Vibration / Acceleration
➢ Sensor embedded in rail
➢ Simple insertion process
➢ Drill
➢ Size
➢ Insert
Copyright © 2021103
Train Handling and Train Make-
Up (Marshalling) Rules
In-train forces are additive to all the other
forces occurring at the wheel/rail interface.
High or Excessive in-train forces can cause a
marginally stable vehicle to derail on marginal track
conditions.
Every effort must be made to minimize the
development of excessive drawbar forces (static
& dynamic), and to limit the development of
excessive lateral forces due to coupler
angularity
Copyright © 2021104
Train Handling and Train
Make-Up Rules
• Must limit traction and dynamic braking forces consistent
with the strength of the couplers and track structure.
• Powered axle limitations
• Proper tonnage limits for the territory
• Prescribed train handling rules for difficult territories
• Prescribed air brake rules
• In undulating territory, moderate reductions in speed can
dramatically reduce slack action due to kinetic energy in
train
• Speed limits for certain vehicles (empty tanks, bulkhead
flats, centerbeams)
Copyright © 2021105
• Proper trailing tonnage limits behind empty vehicles
• Based on maximum curvature on route
• Based on expected buff and draft forces
• Based on long-car short car coupler limits
• Restrictions on tonnage behind Long/Short cars
• Restrictions on number and placement of EOC units
• Restrictions on placement of doublestack and spine
cars; loading definitions on platforms
• Restrictions on number of non-alignment locomotives
in consist
Train Handling and Train
Make-Up Rules
Copyright © 2021107
Root Cause of Human Factor Accidents
Failure to secure train
Failure to observe speed limit Failure to observe signal
Copyright © 2021
Human Error
✓Fallibility is part of the human condition
✓We Can’t change the human condition
✓We can change the conditions under which people work
✓The challenge of root cause analysis is to find the latent and organizational conditions leading to failure – and change those.
108
Copyright © 2021
Human Factor Derailments
• Human failures are steady or slightly increasing in rail
industry – not a good trend
• Human factors derailments are preventable
• Too many Human Factor Derailments are repeat
offenders
• Discipline is often the only corrective action being
used by many railroads; more proactive approaches
are needed
109
Copyright © 2021110
There has been a lot of recent neuroscience
research on human behavior in safety critical
industries
2 sections of the Brain have been implicated:
1. Automatic Habit System
2. Conscious Executive System
Tip: Excellent book on Human
Performance
Copyright © 2021
Objective: Develop Strategies
to reduce human failures
• Better Job Briefings – Stop and Re-boot when work
plan changes (“Take 1”)
• Equipment Securement and handbrakes
• Blind shoves
• Proper handling of switches
• Train speed
• Never Bottle the air
• Briefings after situation changes
111
Copyright © 2021
Objective: Develop Strategies
to reduce human failures
• Better Efficiency/Rules Testing
• Additional frequency; All Shifts
• Team Blitzes
• All functional areas
• Proper record keeping
• Use of Event Recorder Data
• Daily and weekly reviews for critical train handling territories
• Heavy grades and curves
• Speed compliance
• Proper brake handling on grades112
Copyright © 2021
Objective: Develop Strategies
to reduce human failures• Develop Training Requirements
• New Hires entering industry
• Re-fresher training; territory familiarization training
• New equipment and technology
• High adhesion power
• RCL
• DPU
• Situational Awareness (Attention) Training
• Randall Jamieson & Dr. Smilek from Atticus Consulting
• Confidential Close Call Reporting (C3RS, CIRAS)
• Ongoing corporate review of rules, bulletins, procedures
113
Copyright © 2021
A Very Important Point:
Reducing Human failures,
unsafe acts, unsafe
conditions, and human errors
has a profound effect on
improving the reliability and
productivity (PSR) of the entire
organization!!!
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12. Constantly Evaluate
Drainage Conditions along
your ROW
(Ditch, Ditch, Ditch)
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Recent large derailments caused by washouts and
involving crude, ethanol and other hazmat
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Drainage Issues• FRA regulation: “Drainage …must accommodate the
expected flow of water”
• The expected flow of water is a moving target as
North America becomes more “urbanized”.
• Water Run-off from roofs and pavement hit the
drainage ditches in a matter of minutes. Rapid
volume can easily overwhelm existing drainage.
• Railroad must constantly evaluate adequacy of
drainage and water carrying facilities in light of
nearby developments.
• If not a catastrophic failure (washout), poor
drainage/water management is the root cause of
many track geometry defects and track buckles.
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• There are approximately 10+ million wheels running
around north America…some have thin flanges, tread
hollow, and other defects.
• Every day, a defective wheel may show up at your
interchange, and enter your railroad.
• You cannot control the 10+ million wheels, but you
can control/maintain your turnouts.
✓Switch point gapping, fit-up (snuggly)
✓Switch point throw
✓Heel blocks fully supported and tight bolts
✓All bolts and braces tight
✓Guard Face and Guard Check within spec
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13. Maintain your Turnouts
Baker’s Dozen Bonus!!!
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Conclusions
1. Not all these strategies may be appropriate for your
railroad; nor may budgets support them
2. Evaluate where your railroad is weak; pick the low
hanging fruit with available resources. Start small
and build on your successes.
3. This is not an all-inclusive list, keep a full court press
on all possible defects and conditions. At a minimum
insure compliance with standards.
4. Where needed, hire outside help to supplement
existing staff.
5. A good root cause analysis of every incident is an
essential starting point.
Copyright © 2021
Thank You:
Riley Edwards & Emma Jean Ehrenhart
at U. of Illinois
Have a Great Summer
Go See Alaska!
Questions???
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