Railway Age, 11/17/17:
Culture wars, Part 1
Written by David Schanoes
I spent three hours viewing the video archive of the Nov. 14, 2017 National Transportation Safety Board meeting convened to review and approve the findings, probable cause and safety recommendations developed from NTSB investigation into the April 3, 2016 collision of Amtrak 89 with M/W equipment at Chester, Pa., on the Northeast Corridor.
The circumstances of the accident:
SNIP
The cause of this accident is transparently clear to even the most casual observer: the release of the foul time on 3 by the overnight EIC when the track was still obstructed by the backhoe.
The cause of the fatalities is also transparently clear: the failure of the day EIC to ascertain that foul time protection was in place before entering the track and obstructing train movement.
What is not so transparently clear, but is a fact, is that when an accident results because of employee failure to properly comply with and utilize the protections offered and required by the operating rules and procedures, you can bet that while the accident itself may be a “one-off,” the violations are not. You can be sure that the violations of procedure have achieved the status, or near that, of a regular practice, as in “I’ve done it this way 1,000 times before and it’s always worked.”
The video archive of this meeting should be mandatory viewing for those responsible for safe train operations. All the items in the NTSB’s docket (DCA16FR007) should be required reading.
David Schanoes is Principal of Ten90 Solutions LLC, a consulting firm he established upon retiring from MTA Metro-North Railroad in 2008. David began his railroad career in 1972 with the Chicago & North Western, as a brakeman in Chicago. He came to New York 1977, working for Conrail’s New Jersey Division. David joined Metro-North in 1985. He has spent his entire career in the operating division, working his way up from brakeman to conductor, block operator, dispatcher, supervisor of train operations, trainmaster, superintendent, and deputy chief of field operations. “Better railroading is ten percent planning plus ninety percent execution,” he says. “It’s simple math. Yet, we also know, or should know, that technology is no substitute for supervision, and supervision that doesn’t utilize technology isn’t going to do the job. That's not so simple.”
Related: Palmetto (89) vs. Backhoe in Chester, PA; 2 fatalities 4/3/16