Tuesday, December 12, 2017

Culture wars, Part 3

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Culture wars, Part 3

The National Transportation Safety Board, in its investgation into the April 3, 2016 fatal train accident involving Amtrak train 89 and maintenance-of-way equipment at Chester, Pa., made some damning determinations. I do mean damning, as in “leave your pass with the secretary, clean out your desk, and get off the property” damning.

NTSB determined that:

“Amtrak safety programs were deficient...”

“Amtrak did not have a viable reporting system to collect safety critical information...”

“The lack of consistent knowledge and vision for safety across Amtrak’s management created a culture that facilitated and enable unsafe work practices by employees.”

“Amtrak did not have an effective safety management system program.”

Last but not least...

“By delaying progressive system safety regulation, the Federal Railroad Administration has failed to maximize safety for the passenger rail industry and the traveling public.”

I think that’s damning, but then again, I’m a dinosaur. If a president or vice president of operations had ever said those things to me, I would either refute them, or leave my pass with the secretary, clean out my desk, and get off the property. Or both. Probably both. Definitely both.

But that’s the thing about fatal accidents: They make it real hard to claim safety is your first priority. It makes it difficult to argue that you do have a viable reporting system; that your supervisors do effectively supervise your operation; that you do collect safety-critical information and process that information into programs that address vulnerabilities in your safety programs. Difficult? It makes it impossible.

So let’s not argue about that. Let’s look at the other findings and recommendations NTSB has made so we can determine if the findings are accurate, and if the recommendations are viable. We’ll start with this finding: (5) Amtrak did not effectively assure that its employees, especially those in safety sensitive positions, were drug-free while performing their public transportation duties.

NTSB made this determination because the locomotive engineer tested positive for marijuana and that two m/w employees tested positive for cocaine and opiates. That’s bad, for sure, but it hardly means Amtrak has failed to effectively combat the use of drugs on its railroad.

The most effective methods for combatting drug use are the testing programs required by FRA. While testing programs have been in effect for those directly involved with the movement of trains (“hours of service” employees) for 30 years, FRA did not expand the testing requirements to m/w employees until May 2016. Given FRA authority, and its establishment of industry standards for testing and analyzing the samples, individual railroads are not going to “jump over” FRA and impose their own programs. That’s the reality. NTSB may not like that, but that’s how a regulated industry, and a regulator, function.

Amtrak rules have always prohibited the use and possession of drugs and alcohol when on duty, or on the company property, or when subject to duty, like the rules do on every railroad. The rule includes a provision that “an employee may be required to take a breath test and/or provide a urine sample if the Company reasonably suspects violation of this rule.” This applies to all employees, but the determining factor is reasonable suspicion. Without that reasonable suspicion, employees simply cannot be ordered to submit to testing.

There is no indication that any of the employees testing positive for drugs exhibited any behavior that might have supported a “reasonable suspicion” test prior to the accident. Concluding that Amtrak did not effectively combat the use of drugs because Amtrak was not empowered by FRA to test m/w employees for drug use under mandatory and random programs is unwarranted. Of course, the vital failure, and I do mean vital in terms of the authority for train movements, was the removal of the foul time by the night foreman when the track was still blocked by the backhoe.

NTSB rightly points out: (10) Had the two foremen communicated with the train dispatcher jointly about the transfer of fouls from one foreman to the other, it is likely that on-track safety and protection would not have lapsed and the accident would not have happened.

The night foreman had given up his authority over that section of track when the track was still occupied. That a procedure was not in place governing the transfer of foul time was the vital flaw allowing for a physical violation of authority to occupy the track on the part of the m/w equipment. Identifying that as the root cause gives us specific information about what must be done to prevent repeating this horrible accident.

However, NTSB not only immediately jumps away from this safety-critical element and jumps to the failure of Amtrak personnel to use supplemental shunting devices; it confuses positive protection with shunts: (11) The inadequate and inconsistent use of supplemental shunting devices by Amtrak engineering personnel defeated the roadway worker protection component of Amtrak’s Advanced Civil Speed Enforcement System, and thereby place maintenance-of-way employees, equipmen, and the traveling public at greater risk of harm.

In a word, nonsense. The roadway worker component of ACSES II has nothing at all to do with the application of shunts. You can search every document in Amtrak’s PTC docket at www.regulations.gov (FRA-2010-0029) and you will not find a single reference to supplementary shunting devices (SSDs), which play no role in providing positive protection.

PTC systems must prevent unauthorized incursions into a work zone. A shunt does not do that. It downgrades the signal allowing governing entrance to a work zone, if a signal is even present, but it does not even reduce the speed of incursion unless the railroad’s locomotives are equipped with automatic speed control.

The identification and substitution of a speed restriction for positive protection is precisely the “defeating the roadway worker component of ACSES,” which provides protection by enforcing a positive stop when a work zone has been established. The work by the backhoe on 3 Track proceeded safely all through the night without the application of the shunt because a work zone had been established through the proper implementation of foul time.

NTSB continues to misconstrue the cause of the accident, and its solution, by insisting on the safety-critical functioning of shunts, when no such safety critical function of shunts exists: (12) Had the foreman ensured supplemental shunting devices were in place, the accident would not have occurred.

To believe that, one has to believe that had the night foreman applied an SSD after receiving foul time, the same night foreman would have left the SSD in place when reporting the track clear of equipment and personnel and restoring authority for movement to the train dispatcher. No such thing would have occurred. The night foreman would have removed his SSD when releasing the track in expectation that the day foreman would apply his SSD immediately thereafter.

Again, the root cause of the accident is the root cause and cannot be addressed through the advocacy of secondary measures.

We can argue night and day about the use of SSDs for protection of roadway workers, but what we can’t argue about is a) the cause of this accident and b) the limited role SSDs can play, even when properly utilized. Almost 40% of the rail network in the U.S. is “dark territory”—unsignaled. SSDs provide zero protection in that territory.

NTSB, in its attempt at thoroughly explaining the cause of this accident, points to numerous secondary features, and points to some without justification: (23) The personal phone calls made by the day train dispatcher while he was on duty distracted him from performing his job.

There is no evidence of any such distraction. The train dispatcher properly records the turnover regarding the employee-in-charge of the work on 2 Track. The train dispatcher is properly prepared to provide foul time on additional tracks if requested. The train dispatcher did not improperly remove a blocking device and authorize train movement. Did the train dispatcher hesitate when the first signs of the accident appeared on his display panel? Certainly, but I think that delay was a result of the shock and the recognition of what had likely occurred.

NTSB insists: (24) Amtrak’s ongoing infrastructure work creates an increased exposure of roadway workers to incidents like the one at Chester.

Of course any work on the railroad increases the exposure of employees to incidents. That’s why we have established procedures and rules for the creation of work zones. If work zones are not properly established, and if tracks are reported clear that are not clear, then the risk to employees rises. The risk arises from the failure to properly protect the work areas.

NTSB next argues: (25) Had Amtrak instructed dispatchers to operate trains at significantly slower speeds through the Chester work zone, the severity of the accident would have been diminished.

Who would argue with that, except a dinosaur? And you know what? “Ordering trains to operate at significantly slower speeds through the Chester work zone...” is a lot easier said than done. Why? For one thing, the work zone encompassed more than five miles, with the work area moving to different portions of that five-mile stretch. And the work was being done in a four-track section of the railroad. So knowing where and on what tracks to impose the restrictions became problematic.

NTSB is probably not aware of this, but for programmed maintenance work, train dispatchers do not issue speed restrictions. In fact, having the train dispatcher issue the restrictions to each train based on track and the location of the work is least safe way of mandating a reduced speed. A speed reduction should be issued by bulletin order, and the bulletin order should be available before the work even begins. The bulletin order should specify the milepost and the track(s), defining the working limits and the speed.

But wait, there’s more. We don’t just issue bulletin orders with speed restrictions and pretend that solves the problem. We install visual markers along the right-of-way, to advise the train and engine crews, and we set the location of these markers mathematically based on maximum authorized speed and the distance required to reach the reduced speed at the point identified in the bulletin order.

We can automate this process pretty effectively with PTC, through installation of track databases in locomotive on-board computers, and then transmitting the locations of the temporary restrictions prior to the train leaving its initial terminal. Location technologies allow the locomotive to do just that: locate itself on the railroad. But we can’t automate the location of the external visual indicators, and I don’t think anyone is quite ready to discard them from our operating environment. In fact, we can’t. At any given time, for any given train, the on-board apparatus may fail.

If I recall my NORAC rules correctly (MAS 110 mph, work zone speed 30 mph), two “approach” signs (trains can move in either direction on any track), each one placed approximately two miles from each end of the work site, are required. Two working limits “speed” signs would then be placed at either end of the work zone. Two working limits “resume” signs would be placed at the end of the restricted zone. This would have to be done for each track, as any track can be obstructed by m/w equipment, and the signs would have to be moved as the work progresses through the weekend.

In order to erect the signs, the roadway workers would first have to obtain foul time … and we’re right back where we started, with a greater potential for an accident if, in moving and erecting the signs, a track is returned to service before everyone is clear.

Amtrak properly regards positive protection as superior to speed restrictions in protecting work areas. Full disclosure: So do I.

NTSB claims: (26) Amtrak rules and supervisor expectation for dispatchers did not adequately emphasize safety. Quite frankly, if Amtrak rules don’t adequately emphasize safety, then NORAC should never have been accepted as a viable operating platform by FRA, and Amtrak should be shut down. NTSB means something else of course, but when it comes to railroading, you have to say what you mean.

David Schanoes

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.”

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