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RAIU - Runaway locomotive at Portlaoise Loop on the 29th September 2011

Comments

  • #2
    stop
    Registered Users, Registered Users 2 Posts: 890 ✭✭✭stop


    I really expected something like this:

    Unstoppable_Poster.jpg
    :(


  • #3
    Cookie_Monster
    Registered Users, Registered Users 2 Posts: 24,545 ✭✭✭✭Cookie_Monster


    stop wrote: »
    I really expected something like this:
    :(

    the real thing isn't quite as exiting

    neither is the above incident, it rolled a grand total of 306m and then stopped. :eek: :D
    66 As a result of the locomotive not undergoing its last major overhaul, due five months before the accident, the braking system for the locomotive did not undergo routine maintenance prior to the accident occurring which would have included the replacement of the isolation cock. Had the isolation cock been leaking at the time of the scheduled overhaul it would have been replaced at this time (paragraph 55).
    67 Although the locomotive examination conducted 6 days before the accident and passed the ‘Service Brake Exam’ no brake leakage test was conducted (paragraph 56).
    68 The absence of a quality control process applicable to engineering maintenance documentation (paragraph 57) resulted in the FTS Section and the Technical Manager’s not detecting the omission of the brake leakage test as part of the VMIs.

    says it all about IE right there IMO, didn't bother doing scheduled overhaul, didn't bother doing full brake test and no quality control process in place...


  • #4
    dowlingm
    Registered Users, Registered Users 2 Posts: 5,349 ✭✭✭dowlingm


    That only dealt with the maintenance side issues. The chart at para 49 illustrates the driver doing things out of their correct order. Blame is placed that he wasn't trained properly on the most recent revisions of IE procedures. I feel that's not the first time I've read that in an RAIU report.

    Looks like there needs to be more emphasis on continuous retraining (including a more comprehensive set of procedures and not just the ones it's convenient to do on the check ride - para 41) and on checklists, especially given single driver operation doesn't afford a colleague to say "hey bud you're doing that in the wrong order". A comprehensive review would also look at why the driver skipped procedures - could it be (speculation) he felt pressure to rush since presumably the work "his" 071 was due to perform was now 2 hours or so behind where it would have been if an 071 had been in Portlaoise as his duty roster presumed there would be.


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