It's cases like this that make you appreciate the complexity of many serious accidents. It's often a chain of unfortunate cause and effect events rather than a simple mistake.
Yup, in aviation we call it the swiss cheese model (imagine slices of swiss cheese with holes in them, multiple holes often have to line up for a disaster to happen).
You can see the same in basically any air disaster. Planes are incredibly safe machines, and it takes multiple redundant safety failures or operator errors to cause a sever accident. In situations like this, it's almost always a series of unfortunate and unlikely events that lead to the tragedy. Multiple small mistakes that quickly build into a large one
@@Transilvanian90 Yeah, not really. It's like this story I heard on a podcast, where a guy's van is overheating, so he's just panicking putting different fluids into the vehicle. Long story short, he ends up destroying the engine, he didn't address the main problem and instead created a completely new issue. Basically the wrong fluid / oil ended up in the wrong area of the engine. So, during a panic, only wrong choices are made. We never make good choices during a panic, or as is said "the Prometheus school of running away from large objects"
Andre was a hero. I wouldn't have had the mental fortitude to make that order myself. He knew that he would die, but his duty was to his passengers. Rest in peace, sir.
He probably thought he could both make the announcement and survive I feel like many of these people might not do what they did if they genuinely knew they would die Still a hero none the less
@Patriots Nation 4 life honestly I don't think that most people in these kind of situations think about the consequences for themselves, time sorta slows down in a crisis if you are calm, and not panic, but you don't have time to think about tomorrow or even 5 minutes from now, you just have this moment and you have things to do right now
@@ithinkdoyou I agree. Even if Patriots is right and he didn't think he'd die, there has to have been even just a second or two of terror that felt like hours.
Consider the orchestra on the Titanic, which continued to play as other people fled to lifeboats. Consider the Capitol Police in DC, who defended it and besieged Congress members from the violent MAGA mob’s weapons until they were crushed or beaten grievously. There is enormous bravery among us every day, often shown without fanfare or glory seeking. And there is also enormous cowardice, largely from the bullies and fools who want nothing but more power, more control over us, more money, more hero worship.
As a former SNCF worker and a Gare de Lyon dweller, I had many occasion to get in the tunnel. The slope is steep and the trains go down fast. Sometimes I think about it and get the chills.
Seconds before Disaster’s episode on this was also fantastic. It highlighted how Andre Tanguy’s actions were commendable , similar to Coleman’s in the Halifax Disaster
I think by his choices it's clear that he grew up with Seconds from Disaster. I'm pretty sure the king's cross fire is up next and the Kursk sinking will come soon.
This is pretty similar to the 2021 Hualien train derailment in Taiwan, in which the mistakes of one single person caused a deadly chain of events that killed dozens. A flatbed truck from a construction site rolled down a hill onto the tracks just before a tunnel. A train came and hit the truck, derailed, and everything piled into the tunnel which was barely wide enough for 1 train to pass. I will always remember the interview they did with one of the first responders, he was diagnosed with PTSD because the scene was so gruesome. This was what he said: "It was like walking into a human blender, it was dark, there were body parts everywhere, the air was mixed with blood so it was difficult to breathe. I could hear people screaming and crying everywhere but I couldn't see or reach them. If hell ever existed, that was it."
@@lobstrosity7163 "God looks after us all?" I hope this is sarcasm, because it's things like this that make the existence of a compassionate and omnipotent god a complete fantasy.
This happened on my 5th birthday (which makes it the 35th anniversary this summer, I just realised). I think of all the videos on this channel, this one might be the absolute most unfortunate sequence of events. The timetable change, the mother trying to get to her kids on time, the driver's actions on the brakes, the skipped station to make up lost time, the downhill approach, the driver's *other* actions, the general alarm freezing the points, and the packed train waiting at the platform. Really feels like something out of Final Destination when so many freak occurrences have to coincide (including the driver making multiple mistakes that he frankly should not have made).
@@Ryno2094 And if the mom didn't pull the emergency cord, the driver wouldn't have needed to reset the brakes, and if the timetable wasn't changed the mom wouldn't have needed to stop the train. I do agree that most of the fault is on the driver though but there's plenty of other circumstances that might have prevented it from happening.
Imagine the entitlement of thinking that using the emergency brake because the train isn’t stopping where you want it to, and inconveniencing hundreds of other people, is the right thing to do.
"her motives unclear" It was pretty damn obvious that she wanted to get off at that station and didn't realise this train wasn't going to on the new timetable
Paraphrasing from Wikipedia The person who pulled the emergency brake was a young mother named Odile Mirrior. She told investigators that she normally used train 153944's stop at the Le Vert de Maisons station to pick up her children from school. However, she was unaware that the new summer timetable meant that her train would not stop at Le Vert de Maisons. So not wanting to keep her children waiting, she pulled the emergency brake and left the train.
As a train driver from a neighboring country using the same brakes system i remember being shocked as i heard about that driver's course of actions for the first time... I'm not sure what the rules were in France at the time but i'm convinced they didn't allow a driver to just bleed the cylinders and depart without a test of the brakes. Very sad accident made even worse by the fact that it was SO preventable...
Complacency really kills. He probably didn’t think he was doing anything wrong, unfortunately there’s a culture in almost every workplace of “well we do this all the time so no big deal!” And it sometimes leads to tragedy. I work for a railroad as well and ever now and again something will happen that makes us all shudder and wonder what was going through the person or persons heads. This is just a reminder for the rest of us to always follow protocol no matter how annoying it may seem to be, they were written in blood.
I drive trains in Sweden. If I would ever have to bleed any brakes, I would have do a stationary braketest before continuing. And if the train can not show me digitally on a screen that the individual brakes work thought-out the train, I would have to check on indicators in the outside of each individual brakes. And then I would have to do a moving break test when I get to approximately 90 km/h. I can understand the first mistake of this driver but not the rest. But granted, this was a while ago and the attitudes may have been more slacked. I guess we do learn from our predicesers.
As a former conductor in the states it’s mind boggling he cut out the locomotive brakes and proceeded to bleed off each car individually, that’s far from routine rectifying anything with the brake system. They already walked the train bleeding it off but didn’t do a brake set test confirming the last car was set??!! It makes absolutely no sense, especially for someone that’s been operating since a teen and was now in his 40’s.
Bleeding all brakes of all cars, no stationary brake test, forgot he had a magnetic brake? How is that even possible? How can a driver make so many mistakes? We all make mistakes, but this just doesn't make sense.
My mother knows someone who was on the waiting train that day. When passengers were told to evacuate she jumped out of the train and went away without looking back. Many were not so lucky.
@@rebeccacarrington1144 this is really great advice, unfortunately it would only work if I did ever sleep. I've had 8 sleep studies in 2 years and they can't figure my brain out so I just raw dog life on one 16-18hr sleep per 4-7 days. It's unhinged and unhealthy but it's all I got. But yes, no phones is good sleep hygiene for most!
I agree with the Union here. Granted the driver was not blameless in everything but I feel that pinning all the blame on him was the company trying to get out of fixing major issues with their system that led up to what happened.
@@jdmb03 Like @Nostripe361 said, he wasn't blameless (he could have also activated the electric brakes as pointed out), but the overall alarm system was not only pointless, but created more problems than it solved, in averting the collision. The problems were systemic. One person should not unintentionally be able to cause such a disaster while trying to prevent it.
There were definitely issues in the alarm system, especially how it prevented the train from being sent away from the station, and kept the stationary train in place until it was hit.
He didn't seem to know what he was doing. Turning off the main brake valve, bleeding the brakes, contacting the station but not telling them which train he was driving. I cannot speak about company policy as I don't know what that was in 1988, but the fact is, the driver is the captain of his ship. He should know that if anything goes wrong whilst it is under his control, that he should follow policy and call the technician out to check the problem. Ironically, once he started it moving again, that train was never going to stop until it hit something. All he could then do is place his head between his legs and kissing his arse goodbye.
He didn't deserve all the blame, but he did deserve to serve his entire sentence (four years is already extremely generous for 56 counts of negligent manslaughter).
The sequence of events in this tragedy is just one "oh no!" after another. It seems almost like something out of "Final Destination"... condolences to all the victims' families. :(
Over and over again we hear of accidents that happen because of a series of failed procedures. It is both frustrating and frightening. May those who lost their lives rest in peace. And the man who stayed at his post while encouraging passengers to run should be honored as a hero.
It is scary how easily one's actions can lead to such an accident. Hopefully they more thoroughly trained all drivers on how to properly operate the brakes!
It's true, that the driver (Daniel Saulin) should've called maintenance about a defect in his train rather than cut supply to the brakes and manually disarm them and yes as you said about another brake they don't usually do. It's rather scary that the passenger Ordeal Mirrore (I think I said her name wrong) who is a Partisan French resident I think pushed the emergency brake as the train was scheduled to not stop at her station Vert De Maisons.
@@RBMapleLeaf , one is tempted to laid the blame on that woman, but activating an emergency brake should not have this domino effect. Imagine if the brake was pulled because someone fell into the tracks and then this wind up happening.
This episode really lives up to your channel's name. So fascinating how a series of accidents and mistakes can lead to such a horrific outcome. If just one or two of those things hadn't happened the way they did, maybe this would have never happened or at least been a lot less severe.
What a messy chain of events that led to this nightmarish tragedy. Sorry to say I've never heard of this disaster, notice how the pieces always seem to fall into place with horrific consequences.
That’s why they call it a chain of events. If you break a single link then the accident doesn’t happen. Sometimes the chain of events is convoluted and very specific. They often involve multiple people ignoring safety rules
I click on the thumbs up before I even listen to these videos as I know I will enjoy them and learn more history. The narrators voice is perfect and so pleasant to listen to - thank you so much for each and every one!!
I think this was a case of that Swiss Cheese phenomenon. Just the perfect alignment of things going wrong in just the right ways to lead to the worst possible outcome.
I'm astounded that the brake system is not fail safe. On UK trains if there is no brake pressure then the brakes are fully on - the pressure forces the brake off. So "bleeding" the system would have caused the brakes to stay on. This seems like a bit of a fundamental design error to me!
The train was equipped with that same type of fail-safe mechanism. My understanding is that this is what prevented the train from moving when the main brake pipe valve was inadvertently closed, and that the fail-safe mechanism was only defeated by the subsequent action of manually unlocking each brake. Another safeguard that would seem to make sense is that trying to pull other cars with a closed main brake pipe valve closed should be detected and prevented.
Train brakes are not like a trucks brakes. The way they work is by using a charged resivior of air pressure on the car itself, which is what actually applies the brakes when the brake pipe pressure is reduced. The brakes are not sprung onto the wheels, it is air pressure that keeps them applied. There is a return spring, but this is to pull the brakes off the wheels when the brake piston is no longer recieving air pressure. What the driver did was bleed the pressure out of the local reservoirs on the cars, hence why the brakes disengaged. Also, this feature is common to air brake systems around the world. One of the reasons is actually to allow cars to be moved around without their air brakes, specifically to make yard shunting easier. If a cars brakes had to be charged everytime it had to be moved around a yard, it would make shunting jobs take forever. As such the air brakes are only charged and activated for runs on the main line. Train air brakes are fail-safe, but only against an unexpected train separation on the line. If you manually bleed pressure out of the system, or let them sit long enough without being recharged by the brake pipe, they will disengage.
It did fail safe. The brakes were locked. He bypassed that safety by bleeding or the air out of the system. I assume you’re talking about modern air brakes which lock when they have no pressure.
I love these videos because you find out why things are invented or introduced. I knew having been a guard for 3 years on the UK railway that the drivers can override emergency brake applications caused by passengers, but today I found out why and standout one for me was the emergency exit bar due to the incident in the Sunderland theatre
A future video you can do on the deadliest train accident in French history, albeit not during peacetime, was the Saint-Michel-de-Maurienne derailment that occurred on the 12th of December 1917. 675 French soldiers were killed.
Good video as usual. On the Saint-Michel-de-Maurienne disaster of 1917 there is an excellent French documentary of 60 min: ruclips.net/video/98REOnlxRyE/видео.html French subtitles can be translated into English
Aka Modane Saussaz 1917, during France worst year of the war as the poilus threatened revolt as done in Paths of Glory. An overloaded troop train spun out of control down a steep gradient, caught fire and crashed. Most of the occupants burnt to death and could not be identified.
@@duncancurtis5971 That sounds uncannily similar to Quintinshill 1915 (the worst railway disaster in Britain). Except that was a multiple collision not a runaway train, but it involved a troop train and a fire.
@@cr10001 I still remember that story, especially the part where officers and regular soldiers had to shoot their own comrades to give them a quick death. It must have been horrible for them all.
This is very interesting! I worked in Fontainebleau for 6 months in spring 1989 and fall 1990 and rode the train from Fontainebleau to Paris via Melun often, both with the type of equipment that crashed on the suburban (banlieue) line and the faster and more direct RER style trains. I'm thankful that SNCF quickly stepped up to eliminate the causes of the crash and that I didn't know of it at the time!
As a daily passenger of line D at Gare de Lyon, I see the memorial on the platform everyday, and I can't help but think about this catastrophe everyday the train is delayed and stuck at GDL
the pneumatic valve was also confusing with closed position being parallel to the pipe, and also a high degree slope just before the gare de lyon made the train goes from 30km/h to 70km/h. this is some final destination stuff.
Accidents like this are why you should perform a thorough inspection of your equipment before setting off, including testing the brakes. Especially if you've been messing with things. In trucking it actually used to be commonplace in the pulling of tandem trailers to isolate the brakes of the rearmost trailer if that trailer was empty. This would prevent those wheels from locking up in an emergency, but also concealed any potential leaks. Anti-lock brakes have made this practice redundant.
Very well presented. I was just thinking about what you said about the emergency worker response time. In a well populated area, ten minutes is a very long time...
It's alwaus nice to see a video about my home country events. I knew about this one but you do tell the story with reel talent. As I said on another video, have you already spoken about the Bazar de la Charité fire ? It's quite a subject.
This incident is a perfect breakdown of natural human behavior: every one of us have acted like the main participants at some point or another: the mother who did something rather careless when she faced the possibility of being late (if you've ever driven a car, you probably have), Saulin who in a moment of extreme stress forgot basic training, and Tanguy who went above and beyond for others. Lest you think I'm vilifying Saulin for his actions, he did show extreme concern for the passengers on his train. By hurriedly alerting them of the danger and escorting them to the rear carriages, he protected them from serious impact. I really consider this to be a disaster caused equally by human error and a combination of company culture, corporate mismanagement, and design flaws. With a little imagination and a more macro look at the way the line was set up, a disaster like this could probably have been anticipated.
Ah I remember sending you a suggestion about that awful disaster a few months ago. I don't know if it's linked at all, but in any case, thank you for speaking of what happened so accurately.
I was a teen when I went to Paris for the first and, (thus far,) only time. It was 2001. I didn't speak but a few words of French and I didn't realize I missed my stop on the tram. I ended up pulling into the parking area shown at 6:40. The train parked, shut off and locked all entries and exits, including emergency exits, aside from breakaway windows. I ended up pounding on the exit door for some time until someone noticed my noise and came to let me out. It was a strange experience to be in a train, silent and empty, trapped and in a foreign place. I wonder who that stranger was... if they went home and laughed at the trapped tourist.. if I was a piece of the conversation of others for such ridiculous reasons. Thanks; to my unknown hero.
Andre Tanguy could have gotten up and saved himself. But chose to sit there, staring down certain death just to give some strangers a chance to escape.
It's cold and disgusting in North Texas, US of A 🥶. Just your lovely drawl (wait, that's mine); simply hearing your accent from (I'm sorry? I didn't catch that..) and that familiar intro 🎶 have made my day! Thank you for what you do!
Talk about a cluster fck..... Every part of this disaster was so small but the snowball ended up so big. Fantastic video! Hats off to the conductor who sacrificed himself.
Same here. It's because, rather than some amorphous horror that _might happen,_ lurking beyond prediction? Here is this disaster, that we can analyze, learn from, and prevent from recurring. It turns the unknown dread into a known, controllable fear. Very soothing. ...I hate meditation, but I do find it helpful. Cheers.
Andre was the real hero in this tragedy. That kind of act takes enormous fortitude and courage. Another very well, respectfully done video. I’d never actually heard of this one. I can definitely tell you this- that woman may not have faced any legal consequences, but she undoubtedly suffered from a great deal of guilt and self recrimination for what happened… even though it was certainly not her fault the driver didn’t follow protocol.
I don’t get why the woman didn’t just leave at the next stop. I also don’t understand why they punished the driver with years of prison over a mistake that was caused by placement of levers, not merely negligence
It all depends on how far it was going to be for the mom to walk, how little her kids were, and how unforgiving the school/daycare was regarding late pick ups. Who knows what kind of stress she was under. It took some guts for her to come forward.
@Nicole of Nowhere she got the punishment she deserved. She was stupid and selfish but she did not cause those deaths. The driver on the other hand? Definitely guilty of manslaughter through gross negligence. Multiple actions on his part first caused and then exacerbated the situation. He was arrogant in failing to follow established maintenance procedures. He was then negligent in his failure to follow emergency procedures. SNCF setup made some contribution but the union was wrong: the driver deserved to be convicted, as indeed did the guard for his actions in helping bleed the brakes.
@The Corned Beef Council that is where some of SNCF's blame could be brought in. However it was him and him alone who made the brake bleeding decision. It was him and him alone who made the decision to break procedure and not get the brakes inspected.
Damn I love your videos bro. They’re always perfectly done. You always tell a very clear and concise story, with just enough detail to understand what exactly happened, without being too short or too long. On subject though, it’s amazing just how many issues intersect before disaster happens. In this case there were multiple issues that resulted in a horrific crash, but the driver still could have minimised it had he used the electronic brakes. I’m glad the driver didn’t get too long in prison though. He was definitely negligent, but he was also overworked and attempting to rectify the situation. I agree that it’s better to address the systemic issues rather than blame it all on one man. They say that OH&S rules are written in blood, but it’s a shame that it was such a large scale disaster with so many lives lost for these fixes to finally be put in place. Thanks again for a great video, mate. I appreciate your hard work.
A complex case and a series of systematic failures with unfortunate casualties and injured, which led to changes in the years ahead, all of which you masterfully put together in a good and clearly understood way. If you aren't a higher education teacher you very well could be. Thank you for this story!
I'm not a train engineer, but I am a mechanical engineer. The 1872 Westinghouse automatic airbrake is a "fail-safe" system. Air pressure is needed to release the brakes, instead of being needed to apply them. This way, if there is a loss of air pressure in the system, the brakes apply automatically, and can't be released until air pressure is reapplied. Why would SNCF use a system that wasn't "fail-safe," when this technology has existed for 150 years?
No, you are suffering from a common misconception of how train brakes work.. The pressure reduction opens a valve allowing stored air to apply the brakes, the spring hold the brakes off the wheel not on as in a truck. A train with no air at all is still a runaway. en.wikipedia.org/wiki/Railway_air_brake#:~:text=The%20Westinghouse%20system%20uses%20air,air%20stored%20in%20its%20reservoirs.
This in fact was a classic Westinghouse-style air brake, which is fail-safe in theory, but only under certain conditions. The issue is that it uses compressed air as the source of braking force. Decrease in brake pipe pressure is only used as a signal, telling each car (or more precisely, each triple valve) to admit air from brake reservoirs into brake cylinders. There can be no brake application if the system has been bled of air beforehand, which is exactly what happened here.
In moments of adversities, it reveals a man's true character. In moments like this many would choose flight, but ordinary people with extraordinary bravery will always fight and in many disasters these individuals made a huge difference. Rip andre
So frustrating when you know this tragedy could have been entirely avoided once the driver knew something was wrong with the brakes he should have just allowed all the passengers to disembark and call for help
It would have taken less than 5 years to let the passengers of the train I'm sure considering the circumstances they would have understood the situation and the driver could easily have called for help to help resolve it at least no one would have ended up getting killed if the driver did they instead of assuming to know what he was doing and could handle it himself when he clearly couldn't
Actually that was also the procedure. In the situation according to the handbook he should have called over the maintenance crew who would have spotted the error easily. Also the train actually did have a secondary regenerative break. Activating that and using the single pneumatic break still left would have been enough breaking power to stop the train. The regenerative break also is a toggle switch which means you active it and it will keep going so if he was worried about his passengers he could have still activated it before leaving the cabin. It wouldn't have stopped the train completely but it would have slowed it down significantly. Not to mention when he called for help he forgot to give his identity which meant the controllers couldn't divert the train to an empty platform because they had no idea which train the distress call came from.
True, but her actions should have had no impact. Had the driver followed the safety protocols including checking the brakes were operative after his actions the accident would not have happened as the isolated braking system would have been noted and corrected.
My father was among the rescue team and I still remember him being sleepless for days after that. You can't see it on the pictures, but he discribed what he saw as "butchery". The consequences were really awful...
While the driver does deserve a lot of the blame, I feel like the woman who pulled the EMERGENCY STOP on a train just to avoid being late got off way too lightly. Although I empathize with the panic of realizing you're not going where you're supposed to be, it's just a bafflingly self-centered reaction to me compared to getting off at the next exit and re-planning your route. It was the 80s, not the 1800s. Find a payphone and let the school know you're on your way but running late. As a teacher myself, I can confidently say that, while we might be annoyed with you, we're not gonna throw your kids in the dumpster or something if you're late picking them up.
KatFangz is exactly right. Folks see the word "mother" and immediately turn off their judgment standards. I guarantee that a kid would get torn to shreds for pulling the emergency brake, though.
While I agree, that she had other options then using the emergency break I don't think she deserves anymore then what she got. It wasn't the emergency break that caused the accident. It was the driver not doing what he should have when the breaks weren't working and he even had a backup he didn't use. The emergency breaks are there for passengers to use just in a serious emergency and she got fined for using it otherwise which was correct.
@@TheNelly77 It's got nothing to do with her being a parent, but everything to do with the fact that she didn't actually cause the accident. She exposed an incredibly faulty combination of people breaking procedure left right and center and the tech not working as expected. The emergency brake IS MEANT to be used and is NOT meant to cause a train collision. Hence she clearly didn't deserve to be punished for everything that happened after she pulled it.
@Hephaistos There's a lot of misogyny with this reaction. They're blaming her for the whole thing, not the driver who FORGOT ABOUT THE EMERGENCY BRAKE.
@Hephaistos She should absolutely have faced criminal charges for what she did; it's easy to forsee that if you fraudulently pull a train emergency brake, it might cause problems (a fire, a collision with another train that hits the now randomly stopped train, etc). It's akin to yelling fire in a crowded theater, you're responsible for the subsequent chain of events. Not fully, the driver fucked up too, as did the railway organization, but she's ABSOLUTELY guilty here.
It has some similarities to the Caledonian Sleeper near miss a few years ago, specifically a (likely) inadvertent movement of a brake isolating handle, a failure to recognise that the train brakes were not functional, and downward gradients increasing the speed of the train on approach to a station. Luckily in the Caley Sleeper's case, controllers were able to give the train a clear path through Edinburgh Waverley.
You see... when you said the woman's motives left the other passengers baffled, the first thing to come into my mind was "Karen who said to herself, 'Oh yes the train WILL stop here for ME!'" And sure enough...
This video does play the driver as totally incompetent, maybe also the system was also incompetent for the lack of regular Emergency training for the drivers...
Fascinating video… my only comment is that the collision itself was not adequately described like these events usually are in these wonderful videos. I knew it was coming, but the way it was presented was anti-climactic, and left me a little puzzled when he started talking about the video in the past tense. Nonetheless, this was another outstanding story from recent history, that I do remember - although barely - when it happened.
The issue was thr French railway system and its equipment and training, not some woman. This was a ticking time bomb and one that could've been used by terrorists at the time if someone put it together
you really cant blame this on the woman. emergency brakes are for emergencies, and one may argue if this was an emergency or not, but THIS should NEVER be a result of pulling the emergency brake.
Years ago I did an accident investigation into something and I concluded that an accident is when it is only a financial loss. Disaster is when lives are lost. Unfortunately, both seem to be essential in developing and improving safety standards and we hope that lessons learned are not forgotten. It is only because of Titanic sinking, that lifeboats became more of a thing. And it is disasters like Gare de Lyon that safety systems are forced to improve. It is sad for the lives lost, but more lives are saved as a result.
@@neilbadger4262 Going out on a limb to defend the Titanic designers, she was overstocked on lifeboats to the letter of the law. Furthermore, lifeboats werent that safe back then, especially if the wind and seas picked up.
All the holes the Swiss Cheese lined up for this to happen didn't they? It won't do him any good but I hope Andre was awarded a posthumous bravery medal for his sacrifice and his family is well taken care of.
‘He forgot there was another emergency way to stop the train!’ That is the train conductors fault. He is responsible for the deaths & injuries to the passengers. The fact that he only served 6 months is tragic!!!!😢
The fact that they'd been with the company for so long was probably the problem. I think a lot of us can relate to working with people who don't know about anything that has come out in the last 10 years and don't care either. The fact that train operators wouldn't avail themselves to resources right there on their own train, after doing some harebrained modifications themselves, smacks of people who mistook their experience for competence.
Huh. This is another (train) disaster I both hadn't heard of and am surprised that even more people didn't die, especially considering it's another instance of slamming into another train.
What made this crash so devasting was also that the other train was in a one way station. It had no where to go so absorbed the full force of the impact.
Seeing as the runaway train's driver had moved most of his passengers rearward, presumably the majority of the fatalities were on the stationary train waiting at the platform a result of crush type injuries, although conversely probably a lot of the injured came from the moving train through sudden deceleration.
This reminds me of the Tenerife disaster. It's one of those tragedies where an unlikely sequence of incidents and mistakes combine to produce a moment of unimaginable horror. It's like the devil himself is coordinating events.
Comedian Dennis Miller said it best. "I don't think I ever want to be on any form of mass transit where the general public has access to the fuckin' brakes. I'd hate to find out we went off the tracks at 200 miles an hour, because Gus thought he saw a woodchuck".
Classic example of an "Incident Pit"........Lots of small mistakes on their own don't cause serious trouble, but when they all add up together, disaster ensues.
Reminds me of a comedy bit Dennis Miller did about someone pulling the emergency brake on a train. "I don't want to take any form of public transportation where the general public has access to the brakes... I'd hate to find out that we went off the rails at 100 MPH because Gus thought he saw a woodchuck..."
Fascinating, could you please one day do the Granville Train Disaster that occured in the 70s in NSW Australia? There was specific and significant road/rail maintenance oversights. It was our worst transport disaster. And iirc only the Port Arthur Massacre had a higher death toll in general. There was a doco movie for the 25 year remembrance, called Day of the Roses. It's on YT and is reasonably accurate. There was an immense amount of bravery and compassion that day and afterwards. In contrast the behaviour of NSW Rail in matters of compo was appalling. I really hope you can cover it. I'd be happy to do preliminary research at the State Archives. I know you'd give a nuanced but compassionate factual report.
The driver had my sympathy because sometimes sh*t just happens, that is until I find out that there was an emergency brake he could have used! edit: to change guard to driver.
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It's cases like this that make you appreciate the complexity of many serious accidents. It's often a chain of unfortunate cause and effect events rather than a simple mistake.
Good example of a recipe for disaster
Yup, in aviation we call it the swiss cheese model (imagine slices of swiss cheese with holes in them, multiple holes often have to line up for a disaster to happen).
When humans panic and do stupid stuff.
You can see the same in basically any air disaster. Planes are incredibly safe machines, and it takes multiple redundant safety failures or operator errors to cause a sever accident. In situations like this, it's almost always a series of unfortunate and unlikely events that lead to the tragedy. Multiple small mistakes that quickly build into a large one
@@Transilvanian90 Yeah, not really. It's like this story I heard on a podcast, where a guy's van is overheating, so he's just panicking putting different fluids into the vehicle. Long story short, he ends up destroying the engine, he didn't address the main problem and instead created a completely new issue. Basically the wrong fluid / oil ended up in the wrong area of the engine. So, during a panic, only wrong choices are made. We never make good choices during a panic, or as is said "the Prometheus school of running away from large objects"
Andre was a hero. I wouldn't have had the mental fortitude to make that order myself. He knew that he would die, but his duty was to his passengers. Rest in peace, sir.
He probably thought he could both make the announcement and survive
I feel like many of these people might not do what they did if they genuinely knew they would die
Still a hero none the less
@Patriots Nation 4 life honestly I don't think that most people in these kind of situations think about the consequences for themselves, time sorta slows down in a crisis if you are calm, and not panic, but you don't have time to think about tomorrow or even 5 minutes from now, you just have this moment and you have things to do right now
Amen.
I don't think I could have done it. It's amazing that he had the calmness of mind to decide to stay instead of fleeing.
@@ithinkdoyou I agree. Even if Patriots is right and he didn't think he'd die, there has to have been even just a second or two of terror that felt like hours.
Huge respect to Andre Tanguy
He is a real hero of this tragedy...
Never ceases to amaze me that folks like Andre are willing to stick it out until the end to save as many people as possible.
Consider the orchestra on the Titanic, which continued to play as other people fled to lifeboats. Consider the Capitol Police in DC, who defended it and besieged Congress members from the violent MAGA mob’s weapons until they were crushed or beaten grievously. There is enormous bravery among us every day, often shown without fanfare or glory seeking. And there is also enormous cowardice, largely from the bullies and fools who want nothing but more power, more control over us, more money, more hero worship.
@@judeirwin2222 yes. Perfectly stated. Thank you.
@@judeirwin2222 The only Capitol Police fatalities there were heart attacks and self-executions after the event.
As a former SNCF worker and a Gare de Lyon dweller, I had many occasion to get in the tunnel. The slope is steep and the trains go down fast. Sometimes I think about it and get the chills.
👎
Wow. Very interesting
Merci, c’est toujours un accident présent dans les esprits effectivement 😢
It kind of gives me chills the lady only got a fine for such ridiculous selfishness.
The CF was the same game that James Bond played?
Seconds before Disaster’s episode on this was also fantastic. It highlighted how Andre Tanguy’s actions were commendable , similar to Coleman’s in the Halifax Disaster
Seconds from Disaster is just a fantastic documentary in general, but totally agree!
I really miss this docu series.
I was a kid when I watched that episode back in National Geographic Channel.
I think by his choices it's clear that he grew up with Seconds from Disaster. I'm pretty sure the king's cross fire is up next and the Kursk sinking will come soon.
I watched that episode on youtube when I was six. It strangely gives me nostalgia
This is pretty similar to the 2021 Hualien train derailment in Taiwan, in which the mistakes of one single person caused a deadly chain of events that killed dozens. A flatbed truck from a construction site rolled down a hill onto the tracks just before a tunnel. A train came and hit the truck, derailed, and everything piled into the tunnel which was barely wide enough for 1 train to pass. I will always remember the interview they did with one of the first responders, he was diagnosed with PTSD because the scene was so gruesome. This was what he said: "It was like walking into a human blender, it was dark, there were body parts everywhere, the air was mixed with blood so it was difficult to breathe. I could hear people screaming and crying everywhere but I couldn't see or reach them. If hell ever existed, that was it."
That sounds horrible!
God really does look after us all.
God, how awful 😔
@@lobstrosity7163 "God looks after us all?" I hope this is sarcasm, because it's things like this that make the existence of a compassionate and omnipotent god a complete fantasy.
My bbsbbqs
This happened on my 5th birthday (which makes it the 35th anniversary this summer, I just realised). I think of all the videos on this channel, this one might be the absolute most unfortunate sequence of events. The timetable change, the mother trying to get to her kids on time, the driver's actions on the brakes, the skipped station to make up lost time, the downhill approach, the driver's *other* actions, the general alarm freezing the points, and the packed train waiting at the platform. Really feels like something out of Final Destination when so many freak occurrences have to coincide (including the driver making multiple mistakes that he frankly should not have made).
It's called the Swiss Cheese Effect, when all the holes line up bad things happen and this one took a fair few holes to align to make it so.
@@marvindebot3264 Definitely feels like more holes than cheese
But if it wasn't for driver incompetence none of this would have ever happened.
@@Ryno2094 And if the mom didn't pull the emergency cord, the driver wouldn't have needed to reset the brakes, and if the timetable wasn't changed the mom wouldn't have needed to stop the train. I do agree that most of the fault is on the driver though but there's plenty of other circumstances that might have prevented it from happening.
M..
3q0
I like how you also add the after effects of the tragedy in these stories. Like if conditions got better or positively changed.
Imagine the entitlement of thinking that using the emergency brake because the train isn’t stopping where you want it to, and inconveniencing hundreds of other people, is the right thing to do.
Sadly there are plenty of similarly minded people....
"her motives unclear"
It was pretty damn obvious that she wanted to get off at that station and didn't realise this train wasn't going to on the new timetable
Paraphrasing from Wikipedia The person who pulled the emergency brake was a young mother named Odile Mirrior. She told investigators that she normally used train 153944's stop at the Le Vert de Maisons station to pick up her children from school. However, she was unaware that the new summer timetable meant that her train would not stop at Le Vert de Maisons. So not wanting to keep her children waiting, she pulled the emergency brake and left the train.
Agreed, she inconvenienced everybody on that train just because SHE had to get off.. typical. I hope guilt destroys her mind.
@@Victor-sk8by She just stopped a train. Bruh. Im pretty sure it's not her fault this accident happened.
@@titandarknight2698 it’s called emergency brake for a reason lol
Or maybe she was psychic and had a bad feeling.
As a train driver from a neighboring country using the same brakes system i remember being shocked as i heard about that driver's course of actions for the first time... I'm not sure what the rules were in France at the time but i'm convinced they didn't allow a driver to just bleed the cylinders and depart without a test of the brakes. Very sad accident made even worse by the fact that it was SO preventable...
Complacency really kills. He probably didn’t think he was doing anything wrong, unfortunately there’s a culture in almost every workplace of “well we do this all the time so no big deal!” And it sometimes leads to tragedy. I work for a railroad as well and ever now and again something will happen that makes us all shudder and wonder what was going through the person or persons heads. This is just a reminder for the rest of us to always follow protocol no matter how annoying it may seem to be, they were written in blood.
I drive trains in Sweden. If I would ever have to bleed any brakes, I would have do a stationary braketest before continuing. And if the train can not show me digitally on a screen that the individual brakes work thought-out the train, I would have to check on indicators in the outside of each individual brakes. And then I would have to do a moving break test when I get to approximately 90 km/h.
I can understand the first mistake of this driver but not the rest. But granted, this was a while ago and the attitudes may have been more slacked. I guess we do learn from our predicesers.
The mOtHeR 🤡shouldn’t have even pulled the emergency stop in the first place! Send that bytch to prison!!
As a former conductor in the states it’s mind boggling he cut out the locomotive brakes and proceeded to bleed off each car individually, that’s far from routine rectifying anything with the brake system. They already walked the train bleeding it off but didn’t do a brake set test confirming the last car was set??!! It makes absolutely no sense, especially for someone that’s been operating since a teen and was now in his 40’s.
Bleeding all brakes of all cars, no stationary brake test, forgot he had a magnetic brake? How is that even possible? How can a driver make so many mistakes? We all make mistakes, but this just doesn't make sense.
My mother knows someone who was on the waiting train that day. When passengers were told to evacuate she jumped out of the train and went away without looking back. Many were not so lucky.
I don't love insomnia but I DO love getting your notifications at 3:00am. Thank you for your amazing videos.
3 AM gang rise up!
@@myrojyn might as well since we aren't sleepin 😂
Do yourself a favor and mute notifications while you sleep, your brain chemistry will thank you
@@rebeccacarrington1144 this is really great advice, unfortunately it would only work if I did ever sleep. I've had 8 sleep studies in 2 years and they can't figure my brain out so I just raw dog life on one 16-18hr sleep per 4-7 days. It's unhinged and unhealthy but it's all I got. But yes, no phones is good sleep hygiene for most!
My ear is ringing 8[
Andre was basically doing the "captain goes down with his ship" principle, RIP to him and the passengers.
9:32 If I die and this is what they give me for a memorial then I want somebody to get fired!
lmao best comment
I paused for awhile, staring at it, trying to figure out how on earth it memorialized the victims. I could not!
Honestly, a plaque detailing the events of that day with names of the victims would have been just fine.
I agree with the Union here. Granted the driver was not blameless in everything but I feel that pinning all the blame on him was the company trying to get out of fixing major issues with their system that led up to what happened.
He bled the brakes, it was his fault. He had no right to bleed the brakes.
@@jdmb03 Like @Nostripe361 said, he wasn't blameless (he could have also activated the electric brakes as pointed out), but the overall alarm system was not only pointless, but created more problems than it solved, in averting the collision. The problems were systemic. One person should not unintentionally be able to cause such a disaster while trying to prevent it.
There were definitely issues in the alarm system, especially how it prevented the train from being sent away from the station, and kept the stationary train in place until it was hit.
He didn't seem to know what he was doing. Turning off the main brake valve, bleeding the brakes, contacting the station but not telling them which train he was driving. I cannot speak about company policy as I don't know what that was in 1988, but the fact is, the driver is the captain of his ship. He should know that if anything goes wrong whilst it is under his control, that he should follow policy and call the technician out to check the problem. Ironically, once he started it moving again, that train was never going to stop until it hit something. All he could then do is place his head between his legs and kissing his arse goodbye.
He didn't deserve all the blame, but he did deserve to serve his entire sentence (four years is already extremely generous for 56 counts of negligent manslaughter).
I wait for this every week. Congratulations on cracking a MILLION!
The sequence of events in this tragedy is just one "oh no!" after another. It seems almost like something out of "Final Destination"... condolences to all the victims' families. :(
These videos could be longer, but I do like that they're not made overly dramatic and mostly let the situation speak for itself
Over and over again we hear of accidents that happen because of a series of failed procedures. It is both frustrating and frightening. May those who lost their lives rest in peace. And the man who stayed at his post while encouraging passengers to run should be honored as a hero.
Andre Tungay's actions were heroic, saving the lives of passengers while sacrificing his own. RIP Andre
It's so sad that we can only fix problems that we know about, and oftentimes we only know about them after it's too late.
Just what I need to watch before my morning commute.
Really wish you'd do the 1950 Kew Gardens LIRR crash.
Go to the video description and there is a link there to suggest incidents
It is scary how easily one's actions can lead to such an accident. Hopefully they more thoroughly trained all drivers on how to properly operate the brakes!
Perhaps stupid females will refrain from using the Alarme, just to leave the train.
I am female.
It's true, that the driver (Daniel Saulin) should've called maintenance about a defect in his train rather than cut supply to the brakes and manually disarm them and yes as you said about another brake they don't usually do. It's rather scary that the passenger Ordeal Mirrore (I think I said her name wrong) who is a Partisan French resident I think pushed the emergency brake as the train was scheduled to not stop at her station Vert De Maisons.
It's a great example of the Swiss cheese theory.
@@PruneauYT it is, very much so. So many things had to line up to allow this tragedy to happen (as is often the case).
@@RBMapleLeaf , one is tempted to laid the blame on that woman, but activating an emergency brake should not have this domino effect. Imagine if the brake was pulled because someone fell into the tracks and then this wind up happening.
This episode really lives up to your channel's name. So fascinating how a series of accidents and mistakes can lead to such a horrific outcome. If just one or two of those things hadn't happened the way they did, maybe this would have never happened or at least been a lot less severe.
What a messy chain of events that led to this nightmarish tragedy. Sorry to say I've never heard of this disaster, notice how the pieces always seem to fall into place with horrific consequences.
That’s why they call it a chain of events. If you break a single link then the accident doesn’t happen.
Sometimes the chain of events is convoluted and very specific.
They often involve multiple people ignoring safety rules
I went to Paris about 20 years ago, and even stopped at Gare de Lyon. I only learned about the disaster from this video. Absolutely tragic.
I click on the thumbs up before I even listen to these videos as I know I will enjoy them and learn more history. The narrators voice is perfect and so pleasant to listen to - thank you so much for each and every one!!
This illustrates perfectly how 9/10ths of disasters are a tragic combination of disparate events, which converge into one tragedy.
I think this was a case of that Swiss Cheese phenomenon. Just the perfect alignment of things going wrong in just the right ways to lead to the worst possible outcome.
I'm astounded that the brake system is not fail safe. On UK trains if there is no brake pressure then the brakes are fully on - the pressure forces the brake off. So "bleeding" the system would have caused the brakes to stay on. This seems like a bit of a fundamental design error to me!
The train was equipped with that same type of fail-safe mechanism. My understanding is that this is what prevented the train from moving when the main brake pipe valve was inadvertently closed, and that the fail-safe mechanism was only defeated by the subsequent action of manually unlocking each brake.
Another safeguard that would seem to make sense is that trying to pull other cars with a closed main brake pipe valve closed should be detected and prevented.
Train brakes are not like a trucks brakes. The way they work is by using a charged resivior of air pressure on the car itself, which is what actually applies the brakes when the brake pipe pressure is reduced. The brakes are not sprung onto the wheels, it is air pressure that keeps them applied. There is a return spring, but this is to pull the brakes off the wheels when the brake piston is no longer recieving air pressure.
What the driver did was bleed the pressure out of the local reservoirs on the cars, hence why the brakes disengaged.
Also, this feature is common to air brake systems around the world. One of the reasons is actually to allow cars to be moved around without their air brakes, specifically to make yard shunting easier. If a cars brakes had to be charged everytime it had to be moved around a yard, it would make shunting jobs take forever. As such the air brakes are only charged and activated for runs on the main line.
Train air brakes are fail-safe, but only against an unexpected train separation on the line. If you manually bleed pressure out of the system, or let them sit long enough without being recharged by the brake pipe, they will disengage.
@@andrewlucia865 Thank you very much for this, very informative.
It did fail safe.
The brakes were locked.
He bypassed that safety by bleeding or the air out of the system.
I assume you’re talking about modern air brakes which lock when they have no pressure.
@@andrewlucia865 Thanks for giving us a clear explanation of train air brakes.
I love these videos because you find out why things are invented or introduced. I knew having been a guard for 3 years on the UK railway that the drivers can override emergency brake applications caused by passengers, but today I found out why
and standout one for me was the emergency exit bar due to the incident in the Sunderland theatre
Congratulations on 1 million subscribers! Well done!
Another night of insomnia and I was rewarded with a new video from my favourite person! Thank you for making my morning brighter.
A future video you can do on the deadliest train accident in French history, albeit not during peacetime, was the Saint-Michel-de-Maurienne derailment that occurred on the 12th of December 1917. 675 French soldiers were killed.
It has been covered, if not by this channel, maybe by Plainly Difficult?
Good video as usual.
On the Saint-Michel-de-Maurienne disaster of 1917 there is an excellent French documentary of 60 min:
ruclips.net/video/98REOnlxRyE/видео.html
French subtitles can be translated into English
Aka Modane Saussaz 1917, during France worst year of the war as the poilus threatened revolt as done in Paths of Glory. An overloaded troop train spun out of control down a steep gradient, caught fire and crashed. Most of the occupants burnt to death and could not be identified.
@@duncancurtis5971 That sounds uncannily similar to Quintinshill 1915 (the worst railway disaster in Britain). Except that was a multiple collision not a runaway train, but it involved a troop train and a fire.
@@cr10001 I still remember that story, especially the part where officers and regular soldiers had to shoot their own comrades to give them a quick death. It must have been horrible for them all.
This is very interesting! I worked in Fontainebleau for 6 months in spring 1989 and fall 1990 and rode the train from Fontainebleau to Paris via Melun often, both with the type of equipment that crashed on the suburban (banlieue) line and the faster and more direct RER style trains. I'm thankful that SNCF quickly stepped up to eliminate the causes of the crash and that I didn't know of it at the time!
As a daily passenger of line D at Gare de Lyon, I see the memorial on the platform everyday, and I can't help but think about this catastrophe everyday the train is delayed and stuck at GDL
I commend your efforts in pronouncing the french words
the pneumatic valve was also confusing with closed position being parallel to the pipe, and also a high degree slope just before the gare de lyon made the train goes from 30km/h to 70km/h. this is some final destination stuff.
Really? That's nuts, parallel is open on every single valve I've ever seen/used.
@@marvindebot3264 yes, it was a bad design, they probably corrected it after the accident.
@@djaysenpai One would hope so!
The holes in the Swiss cheese lined up.
It's honestly incredibly that only 56 people lost their lives. Extremely tragic for everyone involved.
Accidents like this are why you should perform a thorough inspection of your equipment before setting off, including testing the brakes. Especially if you've been messing with things.
In trucking it actually used to be commonplace in the pulling of tandem trailers to isolate the brakes of the rearmost trailer if that trailer was empty. This would prevent those wheels from locking up in an emergency, but also concealed any potential leaks. Anti-lock brakes have made this practice redundant.
Seen every video (over time) and love them! The music you use is one of my favorite parts!
Thanks for always consistently uploading and always delivering. Been a fan for a couple years now!
Cheers for the Million, mate!
Great vid FH. I first learned of this disaster from the series Seconds from Disaster. RIP Mr Andre Tanguy, the hero of Gare de Lyon.
Very well presented. I was just thinking about what you said about the emergency worker response time. In a well populated area, ten minutes is a very long time...
Brilliant video. You pack in so much information but keep it easy to follow along
It's alwaus nice to see a video about my home country events. I knew about this one but you do tell the story with reel talent. As I said on another video, have you already spoken about the Bazar de la Charité fire ? It's quite a subject.
Oui, bonne idée !
THANK YOU for that one, I suggested it a while ago.
That catastrophe had been a catalyst for the french railway company.
This incident is a perfect breakdown of natural human behavior: every one of us have acted like the main participants at some point or another: the mother who did something rather careless when she faced the possibility of being late (if you've ever driven a car, you probably have), Saulin who in a moment of extreme stress forgot basic training, and Tanguy who went above and beyond for others. Lest you think I'm vilifying Saulin for his actions, he did show extreme concern for the passengers on his train. By hurriedly alerting them of the danger and escorting them to the rear carriages, he protected them from serious impact.
I really consider this to be a disaster caused equally by human error and a combination of company culture, corporate mismanagement, and design flaws. With a little imagination and a more macro look at the way the line was set up, a disaster like this could probably have been anticipated.
Ah I remember sending you a suggestion about that awful disaster a few months ago. I don't know if it's linked at all, but in any case, thank you for speaking of what happened so accurately.
I was a teen when I went to Paris for the first and, (thus far,) only time. It was 2001. I didn't speak but a few words of French and I didn't realize I missed my stop on the tram. I ended up pulling into the parking area shown at 6:40. The train parked, shut off and locked all entries and exits, including emergency exits, aside from breakaway windows. I ended up pounding on the exit door for some time until someone noticed my noise and came to let me out. It was a strange experience to be in a train, silent and empty, trapped and in a foreign place. I wonder who that stranger was... if they went home and laughed at the trapped tourist.. if I was a piece of the conversation of others for such ridiculous reasons. Thanks; to my unknown hero.
Andre Tanguy could have gotten up and saved himself. But chose to sit there, staring down certain death just to give some strangers a chance to escape.
Thanks!
It's cold and disgusting in North Texas, US of A 🥶. Just your lovely drawl (wait, that's mine); simply hearing your accent from (I'm sorry? I didn't catch that..) and that familiar intro 🎶 have made my day! Thank you for what you do!
Talk about a cluster fck..... Every part of this disaster was so small but the snowball ended up so big. Fantastic video! Hats off to the conductor who sacrificed himself.
So happy to see you ! Your videos ease my anxiety, somehow. l
Same here. It's because, rather than some amorphous horror that _might happen,_ lurking beyond prediction?
Here is this disaster, that we can analyze, learn from, and prevent from recurring.
It turns the unknown dread into a known, controllable fear.
Very soothing.
...I hate meditation, but I do find it helpful. Cheers.
Andre was the real hero in this tragedy. That kind of act takes enormous fortitude and courage. Another very well, respectfully done video. I’d never actually heard of this one.
I can definitely tell you this- that woman may not have faced any legal consequences, but she undoubtedly suffered from a great deal of guilt and self recrimination for what happened… even though it was certainly not her fault the driver didn’t follow protocol.
Another train disaster you might want to cover is the Granville Train Disaster, Sydney in 1977.
Grateful she came forward. This is just once incident after another. Terribly sad indeed.
I don’t get why the woman didn’t just leave at the next stop.
I also don’t understand why they punished the driver with years of prison over a mistake that was caused by placement of levers, not merely negligence
He got out after 6 months.
It all depends on how far it was going to be for the mom to walk, how little her kids were, and how unforgiving the school/daycare was regarding late pick ups. Who knows what kind of stress she was under. It took some guts for her to come forward.
@Nicole of Nowhere she got the punishment she deserved.
She was stupid and selfish but she did not cause those deaths.
The driver on the other hand? Definitely guilty of manslaughter through gross negligence. Multiple actions on his part first caused and then exacerbated the situation. He was arrogant in failing to follow established maintenance procedures. He was then negligent in his failure to follow emergency procedures.
SNCF setup made some contribution but the union was wrong: the driver deserved to be convicted, as indeed did the guard for his actions in helping bleed the brakes.
@@davidpnewton spoken like someone with zero knowledge of the pressures Train Drivers face in these situations.
@The Corned Beef Council that is where some of SNCF's blame could be brought in.
However it was him and him alone who made the brake bleeding decision. It was him and him alone who made the decision to break procedure and not get the brakes inspected.
Damn I love your videos bro. They’re always perfectly done. You always tell a very clear and concise story, with just enough detail to understand what exactly happened, without being too short or too long. On subject though, it’s amazing just how many issues intersect before disaster happens. In this case there were multiple issues that resulted in a horrific crash, but the driver still could have minimised it had he used the electronic brakes. I’m glad the driver didn’t get too long in prison though. He was definitely negligent, but he was also overworked and attempting to rectify the situation. I agree that it’s better to address the systemic issues rather than blame it all on one man. They say that OH&S rules are written in blood, but it’s a shame that it was such a large scale disaster with so many lives lost for these fixes to finally be put in place. Thanks again for a great video, mate. I appreciate your hard work.
We appreciate the amount of information we receive from this. Keep up the good work.
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A complex case and a series of systematic failures with unfortunate casualties and injured, which led to changes in the years ahead, all of which you masterfully put together in a good and clearly understood way. If you aren't a higher education teacher you very well could be. Thank you for this story!
This is, by far, one of the most anguishing episodes ever 😢
Congratulations on passing 1 million subs!
I'm not a train engineer, but I am a mechanical engineer. The 1872 Westinghouse automatic airbrake is a "fail-safe" system. Air pressure is needed to release the brakes, instead of being needed to apply them. This way, if there is a loss of air pressure in the system, the brakes apply automatically, and can't be released until air pressure is reapplied.
Why would SNCF use a system that wasn't "fail-safe," when this technology has existed for 150 years?
No, you are suffering from a common misconception of how train brakes work.. The pressure reduction opens a valve allowing stored air to apply the brakes, the spring hold the brakes off the wheel not on as in a truck. A train with no air at all is still a runaway. en.wikipedia.org/wiki/Railway_air_brake#:~:text=The%20Westinghouse%20system%20uses%20air,air%20stored%20in%20its%20reservoirs.
This in fact was a classic Westinghouse-style air brake, which is fail-safe in theory, but only under certain conditions. The issue is that it uses compressed air as the source of braking force. Decrease in brake pipe pressure is only used as a signal, telling each car (or more precisely, each triple valve) to admit air from brake reservoirs into brake cylinders. There can be no brake application if the system has been bled of air beforehand, which is exactly what happened here.
The fact with the second, electrical brake system got me
The driver was at fault, but only due to bad design. There should be indicators in the cab to show the status of every part of the braking system.
In moments of adversities, it reveals a man's true character. In moments like this many would choose flight, but ordinary people with extraordinary bravery will always fight and in many disasters these individuals made a huge difference. Rip andre
Headline: "Engineer who bleeds brakes of his train is surprised to learn he has no brakes"
Great video, friend! Congrats on 1M subs! 🎉
So frustrating when you know this tragedy could have been entirely avoided once the driver knew something was wrong with the brakes he should have just allowed all the passengers to disembark and call for help
Easy to say when you haven't got bosses pushing you to strict timetables.
It would have taken less than 5 years to let the passengers of the train I'm sure considering the circumstances they would have understood the situation and the driver could easily have called for help to help resolve it at least no one would have ended up getting killed if the driver did they instead of assuming to know what he was doing and could handle it himself when he clearly couldn't
Actually that was also the procedure. In the situation according to the handbook he should have called over the maintenance crew who would have spotted the error easily. Also the train actually did have a secondary regenerative break. Activating that and using the single pneumatic break still left would have been enough breaking power to stop the train. The regenerative break also is a toggle switch which means you active it and it will keep going so if he was worried about his passengers he could have still activated it before leaving the cabin. It wouldn't have stopped the train completely but it would have slowed it down significantly.
Not to mention when he called for help he forgot to give his identity which meant the controllers couldn't divert the train to an empty platform because they had no idea which train the distress call came from.
@@MrMarinus18 "BRAKE," NOT "BREAK"
Oh, boy am I ready to watch this video! I have been waiting patiently for you to upload!
That person who put on the emergency breaks must feel awful.
Here's hoping they do. They got off lightly for their stupidity.
True, but her actions should have had no impact. Had the driver followed the safety protocols including checking the brakes were operative after his actions the accident would not have happened as the isolated braking system would have been noted and corrected.
I hope so - her selfishness caused all this
@@piearm1271 it was a series of small things in succession that cause this
@@piearm1271 regardless her actions are what set everything in motion. All because she didn’t want to be inconvenienced 🤦🏾♂️
My father was among the rescue team and I still remember him being sleepless for days after that. You can't see it on the pictures, but he discribed what he saw as "butchery". The consequences were really awful...
While the driver does deserve a lot of the blame, I feel like the woman who pulled the EMERGENCY STOP on a train just to avoid being late got off way too lightly. Although I empathize with the panic of realizing you're not going where you're supposed to be, it's just a bafflingly self-centered reaction to me compared to getting off at the next exit and re-planning your route. It was the 80s, not the 1800s. Find a payphone and let the school know you're on your way but running late. As a teacher myself, I can confidently say that, while we might be annoyed with you, we're not gonna throw your kids in the dumpster or something if you're late picking them up.
KatFangz is exactly right. Folks see the word "mother" and immediately turn off their judgment standards. I guarantee that a kid would get torn to shreds for pulling the emergency brake, though.
While I agree, that she had other options then using the emergency break I don't think she deserves anymore then what she got. It wasn't the emergency break that caused the accident. It was the driver not doing what he should have when the breaks weren't working and he even had a backup he didn't use. The emergency breaks are there for passengers to use just in a serious emergency and she got fined for using it otherwise which was correct.
@@TheNelly77 It's got nothing to do with her being a parent, but everything to do with the fact that she didn't actually cause the accident. She exposed an incredibly faulty combination of people breaking procedure left right and center and the tech not working as expected. The emergency brake IS MEANT to be used and is NOT meant to cause a train collision. Hence she clearly didn't deserve to be punished for everything that happened after she pulled it.
@Hephaistos There's a lot of misogyny with this reaction. They're blaming her for the whole thing, not the driver who FORGOT ABOUT THE EMERGENCY BRAKE.
@Hephaistos She should absolutely have faced criminal charges for what she did; it's easy to forsee that if you fraudulently pull a train emergency brake, it might cause problems (a fire, a collision with another train that hits the now randomly stopped train, etc). It's akin to yelling fire in a crowded theater, you're responsible for the subsequent chain of events. Not fully, the driver fucked up too, as did the railway organization, but she's ABSOLUTELY guilty here.
It has some similarities to the Caledonian Sleeper near miss a few years ago, specifically a (likely) inadvertent movement of a brake isolating handle, a failure to recognise that the train brakes were not functional, and downward gradients increasing the speed of the train on approach to a station. Luckily in the Caley Sleeper's case, controllers were able to give the train a clear path through Edinburgh Waverley.
You see... when you said the woman's motives left the other passengers baffled, the first thing to come into my mind was "Karen who said to herself, 'Oh yes the train WILL stop here for ME!'" And sure enough...
She should've been criminally charged and done some prison time for that.
what a harrowing and horrific story. My goodness. What a tragedy.
This video does play the driver as totally incompetent, maybe also the system was also incompetent for the lack of regular Emergency training for the drivers...
Fascinating video… my only comment is that the collision itself was not adequately described like these events usually are in these wonderful videos. I knew it was coming, but the way it was presented was anti-climactic, and left me a little puzzled when he started talking about the video in the past tense. Nonetheless, this was another outstanding story from recent history, that I do remember - although barely - when it happened.
Just think, if that lady didn’t pull the emergency stop like she was on a city bus, non of this would’ve happened.
The issue was thr French railway system and its equipment and training, not some woman.
This was a ticking time bomb and one that could've been used by terrorists at the time if someone put it together
@@SudrianTales agreed
you really cant blame this on the woman. emergency brakes are for emergencies, and one may argue if this was an emergency or not, but THIS should NEVER be a result of pulling the emergency brake.
Years ago I did an accident investigation into something and I concluded that an accident is when it is only a financial loss. Disaster is when lives are lost. Unfortunately, both seem to be essential in developing and improving safety standards and we hope that lessons learned are not forgotten.
It is only because of Titanic sinking, that lifeboats became more of a thing. And it is disasters like Gare de Lyon that safety systems are forced to improve. It is sad for the lives lost, but more lives are saved as a result.
@@neilbadger4262
Going out on a limb to defend the Titanic designers, she was overstocked on lifeboats to the letter of the law. Furthermore, lifeboats werent that safe back then, especially if the wind and seas picked up.
Thanks for another greatly detailed video❤
All the holes the Swiss Cheese lined up for this to happen didn't they? It won't do him any good but I hope Andre was awarded a posthumous bravery medal for his sacrifice and his family is well taken care of.
Swiss cheese model! You take emergency preparedness too?
@@ferretyluv 25 years in Fire and Rescue
‘He forgot there was another emergency way to stop the train!’ That is the train conductors fault. He is responsible for the deaths & injuries to the passengers. The fact that he only served 6 months is tragic!!!!😢
Delivered another wonderful overview yet again ❤
👎
The fact that they'd been with the company for so long was probably the problem. I think a lot of us can relate to working with people who don't know about anything that has come out in the last 10 years and don't care either. The fact that train operators wouldn't avail themselves to resources right there on their own train, after doing some harebrained modifications themselves, smacks of people who mistook their experience for competence.
He forgot about a backup brake!!!!?? 😡
Love your narration.
Huh. This is another (train) disaster I both hadn't heard of and am surprised that even more people didn't die, especially considering it's another instance of slamming into another train.
What made this crash so devasting was also that the other train was in a one way station. It had no where to go so absorbed the full force of the impact.
Seeing as the runaway train's driver had moved most of his passengers rearward, presumably the majority of the fatalities were on the stationary train waiting at the platform a result of crush type injuries, although conversely probably a lot of the injured came from the moving train through sudden deceleration.
@@salnaturile8653 IIRC there were no fatalities in the moving train.
Ł
This reminds me of the Tenerife disaster. It's one of those tragedies where an unlikely sequence of incidents and mistakes combine to produce a moment of unimaginable horror.
It's like the devil himself is coordinating events.
He does that sometimes.
Comedian Dennis Miller said it best. "I don't think I ever want to be on any form of mass transit where the general public has access to the fuckin' brakes. I'd hate to find out we went off the tracks at 200 miles an hour, because Gus thought he saw a woodchuck".
The correct spelling here is "brakes", one hopes (although in the case in question, things really did break).
@jediknightjairinaiki560 "BRAKES," not "BREAKS"
@@b43xoit Didn't notice the autocorrect. I'll fix it.
@@jake12466 Didn't notice the autocorrect. I'll fix it.
Classic example of an "Incident Pit"........Lots of small mistakes on their own don't cause serious trouble, but when they all add up together, disaster ensues.
Reminds me of a comedy bit Dennis Miller did about someone pulling the emergency brake on a train. "I don't want to take any form of public transportation where the general public has access to the brakes... I'd hate to find out that we went off the rails at 100 MPH because Gus thought he saw a woodchuck..."
Fascinating, could you please one day do the Granville Train Disaster that occured in the 70s in NSW Australia? There was specific and significant road/rail maintenance oversights. It was our worst transport disaster. And iirc only the Port Arthur Massacre had a higher death toll in general.
There was a doco movie for the 25 year remembrance, called Day of the Roses. It's on YT and is reasonably accurate. There was an immense amount of bravery and compassion that day and afterwards. In contrast the behaviour of NSW Rail in matters of compo was appalling.
I really hope you can cover it. I'd be happy to do preliminary research at the State Archives.
I know you'd give a nuanced but compassionate factual report.
The driver had my sympathy because sometimes sh*t just happens, that is until I find out that there was an emergency brake he could have used!
edit: to change guard to driver.
Very interesting, as usual. Did not knew about this one. Love the way to pronounce French names too :)
If this is the third deadliest train disaster in peace time France what is the second and first one