Safety, translated from planes to trains?

Written by Art Miller 

Amtrak is “adopting a safety management system approach used by commercial aviation” as it responds to the Dec. 18, 2017 derailment of Amtrak Cascades train 501 that killed three people and injured more than 60, a railroad spokesperson told me Jan. 29.

Meanwhile, a retired senior airline pilot says a National Transportation Safety Board (NTSB) investigation update into the derailment released Friday suggests 501’s two locomotive cab occupants were “acting like two solo pilots” in the minutes before the train left the rails and plunged from an Interstate 5 overpass.

Amtrak’s statement yesterday comes on the heels of last Friday’s NTSB investigation update showing an apparent lack of operating crew attention to a 30-mph permanent speed restriction, and a Jan. 29 CNN report highly critical of Amtrak’s Cascades service training programs. The train’s engineer and a qualifying conductor were in 501’s control cab when, on its inaugural run, the train entered a 30-mph curve at an estimated 78 mph.

Amtrak spokesperson Kimberly Wood gave no details concerning the new safety management system or if Amtrak was modifying aviation Crew Resource Management (CRM) protocols credited with leading U.S. passenger airlines to nearly 9 years of fatality-free operations. She also declined to say if Cascades crews were receiving remedial training, taking additional route qualification trips or undergoing new territorial-qualification written examinations or final-check rides. Wood also restated Amtrak’s commitment to “advancing Positive Train Control across the network.”

Minimal Communication

Because they were seriously injured, NTSB interviews with the two Amtrak employees were not conducted until the week of Jan. 15. After reviewing NTSB’s interview summaries, retired USAir Captain Ken Blitchington says they suggest there was “minimal communication” between the two railroad employees. He pointed to two portions of NTSB’s Friday release:

• “The qualifying conductor said there was minimal conversation between him and the engineer during the trip. Instead, he spent his time looking through his paperwork to help learn the territory.”

• “The engineer said he saw mileposts 16 and 17 but didn’t recall seeing milepost 18 or the 30-mph advance speed sign, which was posted two miles north of the curve.”

“CRM (Crew Resource Management) protocols would have required both railroad employees to pre-plan and then talk their way through this sort of operational challenge,” said Blitchington, whose flight experiences ranged from Army O-1 Bird Dog spotter planes in Vietnam to Boeing 767s and Airbus A321s.

“If we were making a complicated approach to LaGuardia or San Francisco, one [of the flight deck crew] would have been flying and the other would have been watching our progress throughout the descent and landing,” Blitchington said during Jan. 29 interview l from his suburban Atlanta home.

In my Jan. 10 blog, I explained how aviation-style CRM protocols including checklists and intra-crew communications could work in concert to reduce railroad human factor failures. If applied to 501’s trip, CRM would have required both the engineer and any other operating crew member in the control cab—including the qualifying conductor in this case—to acknowledge the rapidly passing mileposts, advance signage, and wayside signals leading up to the speed restriction. If a new employee is trying to learn a route, surely there’s no more important physical feature to master than a location where a 79 mph speed limit is reduced to 30 mph.

No Rush To Judgment

However, I strongly cautioned to avoid a rush to judgment about the actions of the train’s engineer and qualifying conductor based solely on a preliminary NTSB investigation update. We’ve got to be very careful here. There are inward-and outward-facing cameras to be examined, and dozens of other facts to assemble. The recently litigated Lac-Mégantic case reminds us that serious railroad accidents are the culmination of a complex series of circumstances and events.

Any causal analysis would also examine the operating practices and safety rules in effect, and whether the railroad employees were following those rules. The two employees may have been performing in precise accordance with Amtrak’s rules. We don’t have details, but perhaps Amtrak is addressing how route familiarization trips are conducted?

We should let the skilled consortium NTSB has assembled complete its investigation before making any final determinations. Who knows what they ultimately might uncover.” Ken Blitchington agreed, noting NTSB is “the world’s best” when it comes transportation accident investigations and that only a fraction of the agency’s investigation is complete.

FRA and NTSB Responses

In other Jan. 29 interviews late yesterday, spokesmen for both FRA and NTSB declined to reveal if emergency orders or safety alerts are being prepared. From FRA’s Washington D.C. headquarters came this emailed statement: “While NTSB continues to investigate the probable cause of the Amtrak 501 accident, FRA has not eliminated or made a determination on any regulatory or enforcement actions at our disposal.”

NTSB was similarly non-committal about any immediate action: “As you may be aware, the NTSB issues the majority of its recommendations at the conclusion of investigations. We may, however, issue recommendations at any point during an investigation if we determine that there are urgent safety issues that need to be addressed.” NTSB said there will be no advance advisories of any recommendations.

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