http://railroadworkersunited.org/metrolink-crash-–-metrolink-crash:-opportunity-make-real-safety-improvements

The Metrolink Crash: An Opportunity to Make Real Safety Improvements
September 23, 2008
The recent crash of a Metrolink commuter train and a
Union Pacific Freight train should provide the impetus to make real
safety improvements which would reduce or eliminate the possibility of
such tragic wrecks in the future. More than two dozen people died,
including the engineer of the Metrolink train, and scores -- including
the crew of the freight train -- were injured, many critically.

The emerging, premature consensus over the following week was that the
engineer of the Metrolink train was preoccupied, texting and receiving
cell phone messages, when he should have been observing wayside signals
that would have informed him of the need to safely bring his train to a
stop. Wasting no time, the California Public Utilities Commission voted
to ban the use of a cell phone device while operating a locomotive. We
can expect such a law to become national in scope in the coming months.

But we miss the point – and the opportunity to create a safer railroad –
if we focus exclusively on the specifics of this one incident and the
human behavior that led to this tragedy. Al Chapanis, Former Professor
of Human Factors at the Engineering Department of Johns Hopkins
University makes the case well: “Everyone, and that includes you and me,
is at some time careless, complacent, overconfident, and stubborn. At
times each of us becomes distracted, inattentive, bored, and fatigued.
We occasionally take chances, we misunderstand, we misinterpret, and we
misread. These are completely human characteristics. Because we are
human and because all these traits are fundamental and built into each
of us, the equipment, machines and systems that we construct for our use
have to be made to accommodate us the way we are, and not vice versa.”

Invariably, workers are prone, on occasion to make mistakes -- fall
asleep, become distracted, fail to follow appropriate safety and
operating rules, become confused, and/or lose their “situational
awareness.” Rather than focus strictly upon worker behaviors in the wake
of industrial accidents, injuries and death, we need to focus on the
underlying structural causes, the hazards that can be eliminated that
can assure that such devastating accidents are not repeated. It should
go without saying, that in the case of this recent horrific wreck, more
than simply a cell phone ban is required.

Not too long ago, alltrains routinely ran with two employees in the cab
of the locomotive. With two sets of eyes and ears in the cab, what one
crew member missed the other could catch. When one became fatigued or
drowsy, the other could step up. When one became distracted or confused,
there was another crew member to assist the other to become refocused on
the task. One can only speculate that had there been that second crew
member in the cab the morning of the Metrolink crash, the two could have
easily communicated the yellow “approach” signal that preceded the red
“stop signal” and the train would have been safely brought to a stop.

But the railcarriers and government regulatorsdecided a few decades ago
that the second crew member was no longer necessary in short distance
commuter train service. In 1999, Amtrak began eliminating the second
crew member from the cab on all runs which were less than six hours
running time between terminals. Amazingly, the major freight carriers
have been chomping at the bit in recent years for single employee
operations of freight trains – trains of 10,000 feet in length and
upwards of 15,000 tons traveling at speed up to 70 mph with a crew
member who routinely works 12 hours a shift!

This has been all part of the whole downsizing of the railroad workforce
and the “streamlining” of the industry to eliminate jobs and cut costs.
In light of the Metrolink tragedy, perhaps we need to revisit the whole
concept of two employees in the locomotive cab.

Another factor, one that the National Transportation Safety Board (NTSB)
is looking into is the question of crew fatigue, schedules and hours of
work for train crews. . "Split schedules are something of great concern
to us," said Kitty Higgins, a member of the National Transportation
Safety Board, which is investigating the crash. The Metrolink engineer
was working his usual 11 ½ hour “split schedule” on the day of the
crash.

The railroad has always expected its employees to work long hours, days
or even weeks at a stretch. In recent years, crew fatigue has been shown
to play a significant role in a number of fatal head-on collisions of
freight trains. The rail industry however, continues to work train crews
ragged, often 12 hours of work plus further on-duty time waiting to be
relieved, to then get just 8 hours off-duty before again being called
for another 12 hour shift. Most freight carriers have harsh attendance
policies, restrict their employees from taking time off and in many
cases make little or no provision for off-days. Unfortunately, the rail
carriers’ have done almost nothing to make train schedules more
predictable, almost nothing to make provision for regular off-days, and
in general seem to not understand nor care to address the problem of
crew fatigue. In light of the Metrolink disaster, we have the
opportunity once again to mandate the structural changes necessary to
ensure that train and engine crews receive adequate and properrest

Now, let’s look back at a scenario in February 1996 where a similar
train crash occurred near Silver Spring, MD. After stopping at a
station, the engineer of an eastbound MARC commuter train #286
apparently had accelerated to 63 mph when he should have restricted his
speed to conform with the prior signal (yellow “approach”) which would
have authorized a slower speed (30 mph) in order to be prepared to stop
at the next signal at Georgetown Junction where Amtrak’s “Capitol
Limited” was crossing from one track to another in front of the MARC
train. Following the wreck, the NTSB made 36 recommendations including
that various technological and safety features be added to that rail
line (such as Positive Train Control, to be discussed below). Certain
measures were taken on some railroads, such as posting signs to alert
engineers when departing passenger stations to run at reduced speed
until encountering the next signal. But essentially things remained the
same.

Here we missed a valuable opportunity to make simple reconfigurations to
the physical plant to make such a crash far less likely. “Approach”
signals should never be placed in advance of a passenger station stop.
It is a simple process to configure the signal system to avoid a
scenario where a train departs a station without aid of a signal
indication. But the rail carriers are not willing to spend the money to
reposition or add certain signals and the Federal Railroad
Administration (FRA) and the government are not willing to mandate they
do this. Had the railroads and the FRA learned their lesson in 1996,
last week’s Metrolink crash may never have happened.

Next, let’s look at technology that could have possibly prevented such a
crash. Los Angeles Mayor Antonio Villaraigosa asked why there wasn’t a
safety device that would have prevented this tragedy. “There needs to be
some kind of failsafe secondary measure to protect against human error,
because two trains on the same track are just unacceptable,” he said.

In fact, such systems have been around for nearly a century. For
example, the Pennsylvania Railroad before the Great Depression installed
“cab signal” systems on some of its main routes, including the line from
New York City to Washington D.C. now owned by Amtrak. These systems
provide additional protection against train wrecks by applying the train
brakes if and when the engineer fails to conform to the wayside signal
which is designed to govern the movement of his/her train. It is tried
and true technology that is in use in some places around the country and
is used effectively on many passenger rail systems through out the
world. But sadly, once again, the rail carriers have not seen fit to
make the necessary expenditures for such protections when they can
simply blame human error every time a fatal accident occurs.

Positive Train Control (PTC) is the latest technology that is satellite
based and has the potential to keep trains from running into each other.
Like automatic train control, PTC has the potential to prevent
devastating wrecks and save countless lives. And once again, the
industry is, at best dragging its feet, and at worst is outright opposed
to its implementation.

"I'm not surprised that once again there has been a terrible,
preventable train collision," Barry M. Sweedler, a former senior
director of the NTSB, who retired after 31 years, told The Los Angeles
Times. "It's extremely frustrating. They (the rail carriers) know what
to do to solve these things." Despite making record profits for more
than a decade now, the rail freight industry is more interested in
paying large dividends to stockholders and paying exorbitant salaries to
CEOs than in providing safe transportation for its customers, a safe
environment for the communities through which it operates and a safe
working environment for its employees.

If every time we witness a tragedy of this proportion we simply point
fingers and lay blame upon individual workers, we miss the opportunity
to correct the underlying problems. The rail carriers would have us
believe that “all accidents and injuries are avoidable” and focus upon
worker behavior modification as the sole way to achieve an “injury and
accident free workplace”. But when we look at the larger picture we see
that accidents and injuries are caused by hazards that can and must be
removed.

Yes, it is vital that workers do their jobs correctly, follow the
operating and safety rules, remain focused and maintain their
situational awareness while on the job. But it is long past time for the
nation’s rail carriers to stop blaming workers and hiding behind
“Behavioral Based Safety Programs”. It’s time the carriers step up to
the plate, make the necessary investment in safety, and responsibly do
their part in hazard reduction and elimination. And it is time for
Congress and the federal regulatory agencies to demand this.

For more information on the Railroad Workers United’s campaign to build
real safety, see the website at www.railroadworkersunited.org

--Ron Kaminkow BLET #51 Amtrak