to prevent a repeat of:
NTSB SPECIAL INVESTIGATION REPORT
STEAM LOCOMOTIVE FIREBOX EXPLOSION
ON THE GETTYSBURG RAILROAD
NEAR GARDNERS, PENNSYLVANIA
JUNE 16, 1995
Link to report
http://www.communityhotline.com/upload/SIR9605.pdf

How many of us have read this or require it to be read by our operating and maintenance staffs as part of their training? Care to share any of your organizations implementation of the NTSB's recommendations (other than those imposed by regulation)?

Mike Tillger

As an industry? I'm uncertain. What happened, in short, was poor quality water clogged her pipes and gauges, a youngster was placed in charge of her boiler water and fire, and untrained personnel were left in charge of a steam locomotive. I can only say that law and rules regarding steam boilers have been tightened and new hoops have been been put in place to make certain indicators are truthful. Quite a few restorations have been tripped up on the need for added precautions in the cab.
The live steam railroad hobby, overall, takes this with seriousness. I'd expect tourist railroads would as well.

We've done enough, not enough and too much, depending on who you ask and about what.

An interesting choice was made: technological solutions to what was essentially a training and qualifications (in both mechanical and operations) based cascade of related problems that reached critical mass. In implementing the technological solutions, many of us found problems we never knew we had....so, that turns out to have been a very good thing in general. But it does leave the training and qualifications thing less than resolved. Unlike Canada, we have no national standard and test for boiler operators, which is good and bad.......like everything else. Steam tractor guys have done more about it than railroaders. Still, it may be comforting to know that the person responsible for safely maintaining and operating a steam locomotive has proven his or her ability to do so before being put in charge of one. You can take the most qualified professionals in the industry, have them engineer and overhaul your engine to better than new standards, and turn it over the the usual suspects who haven't learned anything new and.....apart from a larger margin before critical mass can be reached, nothing has really changed. Continuous learning and improvement (or even awareness) is a positive change.

Right now, the best education is booming. By working with people coming from different approaches in different situations, you learn the good, the bad, and the ugly.......and how to tell them apart. If this is your hobby, and you have a real life and career you're kind of limited. If you take the vow of poverty, do this professionally and live in the dirty past....you can travel and work as you can and gain a lot.

I suppose I'm most concerned about people who pick regulatory nits while not noticing issues that really may be critical that aren't regulated. You can be safe but noncompliant; you can be compliant and unsafe. It just isn't as easy to do either any longer.

dave

Well said. These are words of wisdom that extend to other fields. I help run a complex government computer system. Reams and reams of regulations have been created to help keep these systems from being hacked and thousands are employed to manage the resulting paper work. Many pick nits on details while ignoring glaring holes that put a system at risk.

Bob

I'd agree with my namesake above.

In my opinion, the biggest risk today is that of underqualified people being left to their own devices. Problem is, you can train a person until you're blue in the face but in the end, they'll either "get it" or they won't.

We all came very close to disaster when the SP mike dropped 5 out of 6 fuseable plugs out on the road due to low water a few years ao. Everything I've read indicates that it was human error, rather than an equipment malfunction, that caused it. I've always felt this incident was just as unsettling as Gettysburg in 1995. Perhaps more so because it's not talked about nearly as much.

Dave Crosby

That was the mechanism, not the cause.

The people THOUGHT they were trained. The problem was, their training process had become incestuous. It was a closed family/shop, who did not regularly compare notes with outsiders, books or actual reality (e.g. a teardown). Knowledge is "passed down" within the shop over generations, which means it is susceptible to the"game of telephone", where a message is slightly distorted with each retelling, until errors stack up to the point of becoming critical.

The shop was also a patriarchal one, where dissent gets you ostracized. The Republicans recently had an incident where a beloved and oft-repeated point of rhetoric was called out as being flat wrong. Imagine you're a Republican who actually knew that beforehand. Should you have spoken up? Dare to, injure your party standing and they probably ignore you anyway. Keep your mouth shut and risk the party's embarrassment later. It's a choice between what's good for you, and what's good for the party. ... ... And That's How These Things Happen.

I've done a ton of work on a GE 44, and one of the things I'm fighting is just this sort of politics and patriarchy going before science. For instance, for a dozen years, the Official Standard Procedure has been to Start Engine 1 First, and that is drummed into the brain of every engineer. But here's the thing: the auxiliary generator on engine #2 works, not on engine #1. Start #2 first and you get unlimited tries at starting engine #1. Makes sense, right? Well, that has turned into a political pissing match, because the Patriarchs don't understand the underlying physics, but do understand their own habits, comfort zone and political power. And so the order stands: start engine #1 first. Now I'm not trying to plink on this group. I'm trying to illustrate HOW EASY it is for bad practices to develop and be unmovable.

It could well be that everyone at Gettysburg knew (or had a hunch) they were clearing the sight glass wrong, but they were afraid of being caught doing it in a way not proscribed by the patriarch.

THIS is the core problem, and FRA has done nothing to move the needle on it. Technical expertise is simply not valued by political types. Confronted with a technician who is telling them what they need to know, they can either listen to them and benefit their company... or treat that advice as a challenge to their authority, and make political capital for themselves.

Welcome to the state of discourse in America. Next thing you know, they're going to start excommunicating scientists.

[quote=Welcome to the state of discourse in America. Next thing you know, they're going to start excommunicating scientists.[/quote]

Next? That's been popular for hundreds of years at least, and probably longer. I think of the Scopes trial or the enlightened Texas school textbook idiots equating creationism with evolution which was in the headlines just a year or so ago.......of course we must tread carefully or we'll risk fallling off the edge of the earth and away from the center of the universe.

Why don't we all stand up in support of rationality instead of fighting over different irrationalities? Perhaps that's too rational an approach.......unless Cthulu dictates it.

dave

For the love of...
Can't we have ANY discussion anywhere online where politics doesn't get thrown into it?

I was commissioned to take a serious look at the Gettysburg property shortly after the incident by a prospective buyer. I was acommpanied by a highly repected steam professional and what we found was truly scary and that's an understatement.

It was glaringly evident that there were various pieces of passenger equipment in service with multiple federal violations, many of them highly visible and apparent. The paperwork records were in equally bad shape and much of the reports issued to the Feds contained multiple mis statements of fact.

How no one was criminally charged is beyond me. The other never answered mystery is where were the FRA inspector(s) charged with this property?? What we observed took a good while to get that way and the violations were so obvious even a rookie would have seen many of them??

Only by the grace of God was a total disaster averted.

Let's hope there's no more Gettysburg's out there!!

Ross Rowland

For the love of...
Can't we have ANY discussion anywhere online where politics doesn't get thrown into it?

It seems that on occasion, by revealing one's political leanings, they establish what they consider to be "credibility" with the audience. By letting everyone on this board know where they stand politically, it allows them to assume their identity is masculine, God loving/fearing, heterosexual, and morally just.

I don't feel the need to disclose my political leanings...because I too have/can operate a locomotive and work with heavy machinery. The measure of dedication I have to railroad history, in its' many forms, can not be simplified by whether I am a Republican or a Democrat.

However, I will say this...the day after tomorrow...steam will still grace the rails somewhere in America...regardless of the winner.

Thank you-

I said numerous times that the Gettysburg RR, under the Cornells, was a "time capsule" of exactly the way old-time railroading operated--for better and for worse. In an unfortunately true sense, you saw how a short-line railroad in the Depression or the doldrums of insolvency, unable to abandon service thanks to the ICC or state utilities commission, patched things up with chewing gum, chicken wire, and a fresh coat of surplus-store paint and stretched itself any way it could to make a buck, including running passenger trips that spontaneously turned into "mixed trains." It was the Fiddletown & Copperopolis come to life, in a sense, but some aspects of "living history," such as life being cheap or expendable if you weren't the right kind of person, deserve to be left in the history books or photo albums.

Just as a follow up to Ross Rowland's posting, I do hope 1278 gets a second lease on life. She was a sweet locomotive and her design is one of the saving graces in the incident.
The other incident that cast a spotlight n operating large steam powered equipment, concerned a tractor explosion which wrought heavy destruction and death, about 12 years back(?).

Medina Ohio will live in infamy in the steam traction community just as Gettysburg should be remembered in the steam railroading community.

Well, actually, not. The design was as it was because the Canadian Pacific didn't want to use fusible plugs, which, God forbid, might cause a road failure and take a perfectly good locomotive out of service, so this was their work around. If the locomotive would have been equipped with fusible plugs, this might have been a non-event... exciting at the time, but hardly earth shaking, or industry changing.

Then again, considering the level of maintenance, or lack thereof, at the property, the plugs would likely have been scaled over anyway.

I've worked at places like that in the past, where things were done as they had always been done, and no one could explain why, or even had a full understanding of the issues. Case in point, someone asked on a machinist forum the other day why the Harig Grind-all fixture come with two different size clamp on stops, since they seem to function interchangeable. When no one could come up with the definitive answer, he called the company, which is still in business. Their reply... "Because we've always made them that way."

I had to look it up. I think I remember hearing something about this right after it happened, but this was the first time I saw the location noted. I googled it and looked it up. A horrible crown sheet failure which killed five people and injured a lot of other spectators. It killed the owner/operator so we'll never know what they were doing at the time.
Funny how railroad crown sheet failures are well documented and noted, but you never hear much about the same thing with steam tractors. I'd assume they happend on the farms with about the same frequency back in the day (maybe even more so as railroads at least trained you officially before they'd let you run a steam locomotive) but the incidents weren't as spectacular or well known as I'd assume many of them happened way out in the back 40 of large farms...