Amtrak 501 Derail in Washington State

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Posted by 243129 on Thursday, July 12, 2018 10:25 AM

VOLKER LANDWEHR

So Mr. Landwehr given all this information you have proffered what is your opinion as to the cause(s) of the 501 tragedy?

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Posted by 7j43k on Thursday, July 12, 2018 10:34 AM

The job of an engineer is to operate his locomotive/train in a safe manner.  This one obviously didn't.

But it surely wouldn't have hurt to put up a more eye-catching indicator of danger than a "flag".  Maybe a couple of rotating beacons.  Or would that have been too expensive?  

 

Ed

 

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Posted by 243129 on Thursday, July 12, 2018 10:36 AM

7j43k

The job of an engineer is to operate his locomotive/train in a safe manner.  This one obviously didn't.

But it surely wouldn't have hurt to put up a more eye-catching indicator of danger than a "flag".  Maybe a couple of rotating beacons.  Or would that have been too expensive?  

 

Ed

 

 

Bottom line is Ed, you are supposed to know where you are. Signs can be vandalized, electronic safeguards can fail.

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Posted by 7j43k on Thursday, July 12, 2018 10:55 AM

I don't disagree at all.  I believe the engineer should be charged with manslaughter. And I feel very sorry for him.  I do wonder if additional charges could/should go "upstairs".

But a pilot is supposed to be able to land a plane (actually, HAS to be able).  But they still put all those colored lights out there to help out.  

I find no harm in trying to help the responsible person pull of a safe trip. 

And I think it reasonable to charge anyone vandalizing this kind of sign with attempted murder.

 

Ed

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Posted by 243129 on Thursday, July 12, 2018 11:03 AM

7j43k

I don't disagree at all. 

But a pilot is supposed to be able to land a plane (actually, HAS to be able).  But they still put all those colored lights out there to help out.  

I find no harm in trying to help the responsible person pull of a safe trip. 

 

Ed

 

An engineer HAS to be able to operate his train safely. You must know where you are at all times. You must have that basic intimate knowledge of your surroundings. PTC, cab signal, gps etc. can and do fail and they also promote automated addiction.

https://www.huffingtonpost.com/2013/07/11/automation-addiction_asiana-crash_n_3576059.html

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Posted by 7j43k on Thursday, July 12, 2018 11:08 AM

(I modified my post.)

Yes, I agree.  He MUST be able.....  He didn't.  That is why he deserves jail time.  He screwed up.

But I don't see that as a reason NOT to help him do his job.  Hey.  They could have left the flags off entirely, and said the same thing:  It's your job.

I think management should do everything they can to help labor do their job.  I have a very small business, and that's MY job, as management.

 

Ed

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Posted by 243129 on Thursday, July 12, 2018 11:20 AM

"I think management should do everything they can to help labor do their job."

I agree and proper training would be at the forefront and Amtrak fails to provide that.

I don't think the engineer deserves jail time. He is also a victim. A victim of Amtrak's inadequate hiring and training procedures.

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Posted by BaltACD on Thursday, July 12, 2018 12:01 PM

7j43k
(I modified my post.)

Yes, I agree.  He MUST be able.....  He didn't.  That is why he deserves jail time.  He screwed up.

But I don't see that as a reason NOT to help him do his job.  Hey.  They could have left the flags off entirely, and said the same thing:  It's your job.

I think management should do everything they can to help labor do their job.  I have a very small business, and that's MY job, as management. 

Ed

Can't agree that the engineer deserves jail time.  Those responsible for setting up the 'training program' for the engineers on this route are the ones that deserve jail time.

The incompetence in implementing this segment of 'new' railroad springs from managements actions - actions that did not have each engineer being qulified actually operate real trains over the territory at actual track speeds under the supervision of a Engineer Pilot for as many trips as the engineer being trained felt were necessary for him to be comfortable that he KNEW the territory.  That manner of qualification would have required much more time and money.

The signage displayed was visible in the forward facing camera views and should have been adequate to inform a even minimally qualified engineer of the approaching curve.  In that the engineer took next to no effective actions to reduce speed one can only surmise that he did not reach the level of being minimally qualified on the route.

         

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Posted by charlie hebdo on Thursday, July 12, 2018 12:42 PM

243129

This is addressed to all participants here.

So what conclusion do you draw from all of the above info?

 

I will confine my comments to areas with some expertise. 

The Amtrak engineer, 55 years old, told investigators that on the day of the accident he felt healthy. The only medication he recalled taking in the days prior to the accident was ibuprofen for neck pain. He had previously been diagnosed with Obstructive Sleep Apnea (OSA) and had been regularly using an at-home Continuous Positive Air Pressure (CPAP) machine for treatment, and used a portable CPAP machine when he stayed in a hotel. He had also been diagnosed and treated with medication for diabetes and high cholesterol.

The preceding quote on the engineer's medical condition raises serious questions about his ability to maintain vigilence.

1. He was diagnosed and is treated for sleep apnea.  There is no way of knowing how effective his treatment has been beyond using a CPAP. We do not know, for example, if his treatment plan includes weight loss and if that aspect is being carried out.  We also do not know how effective his CPAP is or how faithfully he uses it. Compromised sleep frequently leads to cognitive processing impairments, including attention and judgment.

2. He has diabetes, likely type 2, as he is prescribed medication.  Again, we do not know how effective his treatment is (diet and medication), determined by labs such as his Hg A1C or his self-monitored serum glucose levels (if he regularly measures it).  Should he have occasional hypoglycemic episodes (not uncommon), cognitive processes such as attention and vigilence could be compromised.

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Posted by 243129 on Thursday, July 12, 2018 1:41 PM

charlie hebdo

 

 
243129

This is addressed to all participants here.

So what conclusion do you draw from all of the above info?

 

 

 

I will confine my comments to areas with some expertise. 

The Amtrak engineer, 55 years old, told investigators that on the day of the accident he felt healthy. The only medication he recalled taking in the days prior to the accident was ibuprofen for neck pain. He had previously been diagnosed with Obstructive Sleep Apnea (OSA) and had been regularly using an at-home Continuous Positive Air Pressure (CPAP) machine for treatment, and used a portable CPAP machine when he stayed in a hotel. He had also been diagnosed and treated with medication for diabetes and high cholesterol.

The preceding quote on the engineer's medical condition raises serious questions about his ability to maintain vigilence.

1. He was diagnosed and is treated for sleep apnea.  There is no way of knowing how effective his treatment has been beyond using a CPAP. We do not know, for example, if his treatment plan includes weight loss and if that aspect is being carried out.  We also do not know how effective his CPAP is or how faithfully he uses it. Compromised sleep frequently leads to cognitive processing impairments, including attention and judgment.

2. He has diabetes, likely type 2, as he is prescribed medication.  Again, we do not know how effective his treatment is (diet and medication), determined by labs such as his Hg A1C or his self-monitored serum glucose levels (if he regularly measures it).  Should he have occasional hypoglycemic episodes (not uncommon), cognitive processes such as attention and vigilence could be compromised.

 

back in the 60s and 70s these conditions that you described would have medically disqualified you as an engineer on the mainline. Amtrak did away with those parameters

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Posted by 7j43k on Thursday, July 12, 2018 2:45 PM

The engineer freely accepted the job of taking the train out.  He's been in the trade for some time, and knows that he is thus affirming he is competent to do the task.

I suppose he could argue that he only THOUGHT he was competent because Amtrak had assured him he was--because he "went through all the requred hoops".

A loose end I'd like to see tracked down is how much conversation happened in the cab.  Conversation can be distracting.

 

Ed

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Posted by charlie hebdo on Thursday, July 12, 2018 2:46 PM

243129

 

 
charlie hebdo

 

 
243129

This is addressed to all participants here.

So what conclusion do you draw from all of the above info?

 

 

 

I will confine my comments to areas with some expertise. 

The Amtrak engineer, 55 years old, told investigators that on the day of the accident he felt healthy. The only medication he recalled taking in the days prior to the accident was ibuprofen for neck pain. He had previously been diagnosed with Obstructive Sleep Apnea (OSA) and had been regularly using an at-home Continuous Positive Air Pressure (CPAP) machine for treatment, and used a portable CPAP machine when he stayed in a hotel. He had also been diagnosed and treated with medication for diabetes and high cholesterol.

The preceding quote on the engineer's medical condition raises serious questions about his ability to maintain vigilence.

1. He was diagnosed and is treated for sleep apnea.  There is no way of knowing how effective his treatment has been beyond using a CPAP. We do not know, for example, if his treatment plan includes weight loss and if that aspect is being carried out.  We also do not know how effective his CPAP is or how faithfully he uses it. Compromised sleep frequently leads to cognitive processing impairments, including attention and judgment.

2. He has diabetes, likely type 2, as he is prescribed medication.  Again, we do not know how effective his treatment is (diet and medication), determined by labs such as his Hg A1C or his self-monitored serum glucose levels (if he regularly measures it).  Should he have occasional hypoglycemic episodes (not uncommon), cognitive processes such as attention and vigilence could be compromised.

 

 

 

back in the 60s and 70s these conditions that you described would have medically disqualified you as an engineer on the mainline. Amtrak did away with those parameters

 

 

A bit harsh and not in keeping with progress. The use of CPAP machines for obstructive sleep apnea was not introduced until 1981 and not widely adopted until the late 1980s.  Improved medications for type 2 diabetes have continually come forth since the 1960s.  These should not now disqualify employment but in both cases, effectiveness of treatment should be monitored closely and be a cause for suspension should it be not being effective.

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Posted by VOLKER LANDWEHR on Thursday, July 12, 2018 4:48 PM

7j43k
A loose end I'd like to see tracked down is how much conversation happened in the cab. Conversation can be distracting.

You might look at the factual report of the Onboard Image Recorder Group.
Regards, Volker

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Posted by charlie hebdo on Thursday, July 12, 2018 5:00 PM

VOLKER LANDWEHR

 

 
7j43k
A loose end I'd like to see tracked down is how much conversation happened in the cab. Conversation can be distracting.

 

You might look at the factual report of the Onboard Image Recorder Group.
Regards, Volker

 

Not all that much conversation, although some laughter.  He does not seem to know the route well and the importance of some signs/signals does not seem to register.  Rain and oncoming headlights seem to reduce his visibility.

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Posted by Miningman on Thursday, July 12, 2018 6:08 PM

Charlie-- That is disturbing. Makes me think of a society in decline. 

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Posted by Euclid on Thursday, July 12, 2018 6:41 PM

That transcript of the in-cab conversation in the On Board Image Recorder Group does not contain a lot of detail, but it is almost eerie in the way that the engineer’s self-deprecating, yet cavalier attitude about getting lost and not knowing seems to correspond well to the actual outcome of this run in which the engineer haplessly runs right into the hell that his inattention has created.  The conversation at the start almost seems strangely prophetic.

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Posted by 243129 on Thursday, July 12, 2018 6:51 PM

Euclid

That transcript of the in-cab conversation in the On Board Image Recorder Group does not contain a lot of detail, but it is almost eerie in the way that the engineer’s self-deprecating, yet cavalier attitude about getting lost and not knowing seems to correspond well to the actual outcome of this run in which the engineer haplessly runs right into the hell that his inattention has created.  The conversation at the start almost seems strangely prophetic.

 

When one is lost, and evidentally this guy was lost, would not the inclination be to slow down?

Poor vetting, poor training, poor supervision. What else could it be? How many more disasters,and there will be more, will it take to force Amtrak to revamp it's hiring and training practices? There are more people and worse out there like Stephen Brown. Amtrak needs oversight in it's operating department.

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Posted by 7j43k on Thursday, July 12, 2018 7:06 PM

VOLKER LANDWEHR

 

 
7j43k
A loose end I'd like to see tracked down is how much conversation happened in the cab. Conversation can be distracting.

 

You might look at the factual report of the Onboard Image Recorder Group.
Regards, Volker

 

 

Could you please give me a link or a way to do so?  Thanks.

 

I did find the interview with the engineer:

https://dms.ntsb.gov/pubdms/search/document.cfm?docID=464926&docketID=61332&mkey=96974

 

I found it interesting.

 

Ed

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Posted by 243129 on Thursday, July 12, 2018 7:45 PM

7j43k

 

 
VOLKER LANDWEHR

 

 
7j43k
A loose end I'd like to see tracked down is how much conversation happened in the cab. Conversation can be distracting.

 

You might look at the factual report of the Onboard Image Recorder Group.
Regards, Volker

 

 

 

 

Could you please give me a link or a way to do so?  Thanks.

 

I did find the interview with the engineer:

https://dms.ntsb.gov/pubdms/search/document.cfm?docID=464926&docketID=61332&mkey=96974

 

I found it interesting.

 

Ed

 

That man should never have been hired for the position of locomotive engineer. He did not possess the acumen for that position. That coupled with Amtrak's horrendous training program was the RX for the disaster. Jonathan Hines, Charles Beatson and the Vice President of Operations should all be held accountable and removed from their positions.

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Posted by 243129 on Thursday, July 12, 2018 7:47 PM

243129

 

 
VOLKER LANDWEHR

 

So Mr. Landwehr given all this information you have proffered what is your opinion as to the cause(s) of the 501 tragedy?

 

 

Mr. Landwehr???

Regards, Joe

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Posted by Euclid on Thursday, July 12, 2018 7:48 PM

243129

 

 
Euclid

That transcript of the in-cab conversation in the On Board Image Recorder Group does not contain a lot of detail, but it is almost eerie in the way that the engineer’s self-deprecating, yet cavalier attitude about getting lost and not knowing seems to correspond well to the actual outcome of this run in which the engineer haplessly runs right into the hell that his inattention has created.  The conversation at the start almost seems strangely prophetic.

 

 

 

When one is lost, and evidentally this guy was lost, would not the inclination be to slow down?

Poor vetting, poor training, poor supervision. What else could it be? How many more disasters,and there will be more, will it take to force Amtrak to revamp it's hiring and training practices? There are more people and worse out there like Stephen Brown. Amtrak needs oversight in it's operating department.

 

I think he was lost, or maybe in and out of being lost, but I am not sure he ever knew he was lost.  What I see is somebody who was just not cut out for the job.  Possibly Amtrak or somebody else could have trained him, but I think the best thing to do would have been not to hire him. 
 
How much training does it take to make him know that he has to remember to slow down for that curve?  A person with that responsibility needs a kind of steely resolve that they will not fail. 
 
The basic problem I see is that the Amtrak engineer is just not wired to have that resolve, and the hiring culture of Amtrak is not wired to see that deficiency in the engineer. Amtrak should not have hired him, but they will hire a hundred more like him without a second thought.  
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Posted by VOLKER LANDWEHR on Friday, July 13, 2018 3:04 AM

 

7j43k
Could you please give me a link or a way to do so? Thanks.

I posted links to the docket and all regarding Factual Reports on page back. Here is again what you are looking for:
Onboard Image Recorder Group: https://dms.ntsb.gov/pubdms/search/document.cfm?docID=465043&docketID=61332&mkey=96974

Regards, Volker

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Posted by VOLKER LANDWEHR on Friday, July 13, 2018 3:48 AM

243129
When one is lost, and evidentally this guy was lost, would not the inclination be to slow down?

As others have already said, to slow down when you are lost you need to realize that you are lost. From the transcript of the crew conversation they only realized it when the locomotve started rotating.

Since when are you so interested in my opinion?

I agree that the engineer was very poorly trained. If I understood correctly the engineer was on a Charger the first time, for me a no go for a revenue trip without supervision.

Regarding Amtrak's hiring I can't say anything. If the engineer was adequate for his job I can't say. Regarding loss of situational awareness and health issues Charlie Hebdo said everything. I agree with BaltACD's post on this page regarding management responsibility.

Yes there is something wrong at Amtrak. But these were just the Factual Reports and not the propable causes. As I don't know Amtrak's procedures in detail I'll have to wait for the final report.
Regards, Volker

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Posted by 243129 on Friday, July 13, 2018 6:32 AM

VOLKER LANDWEHR

 

 

 

 

Since when are you so interested in my opinion?

 

Since you have posted so many links I assumed that you had formed an opinion.

By the way BaltACD's 'opinion' is not unique to him.

Regards, Joe

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Posted by VOLKER LANDWEHR on Friday, July 13, 2018 8:29 AM

243129
Since you have posted so many links I assumed that you had formed an opinion.

Sure I have an opinion. I thought posting links to some NTSB Factual Reports might benefit this discussion.

Here is another link: An article about the second day of the NTSB hearing which discussed passenger rail safety not details of the accidents: https://www.washingtonpost.com/local/trafficandcommuting/amtrak-says-new-focus-on-safety-will-make-rail-travel-safer-for-all/2018/07/11/5fd493ec-8531-11e8-8f6c-46cb43e3f306_story.html?utm_term=.854b3e3eca31

After looking in some Factual Reports I find the second sentence disturbing: The company said it has long had programs that encourage employees to report safety issues, had rules designed to protect workers and collected data to pinpoint weaknesses in its systems. But officials acknowledged there is room for improvement.

If I understand the rest of the article correctly a safety management system is seen as a way to safety improvements. It is only the basis.

When my former employer, Germany's largest construction company at that time, got quality management system certified we realized that it didn't improve the quality but only document what we did, good or bad.

Improving quality or here safety needs a next step. Draw conclusions from the findings in the quality/safety management system and implement them.

Documentation for the management system costs money as well as developing suggestions for improvement from it and implementing them.

Is Amtrak willing to do this?
Regards, Volker

 

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Posted by 7j43k on Friday, July 13, 2018 10:44 AM

Volker,

Thank you for the link.  

"Chilling" is one word that comes to mind.

 

Now that the FAA has airplane safety "up and running", perhaps a few of their folks should be reassigned to the top levels of Amtrak.  Which perhaps needs an attitude adjustment.

 

Ed

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Posted by 7j43k on Friday, July 13, 2018 11:00 AM

Hypothetical:

If I drive a car I'm not used to down a road I hardly know on a dark and stormy night, and I arrive at a curve too fast, swerve, and kill two pedestrians, would it be a surprise if I was charged with manslaughter?  Or would I walk?

I suspect the district attorney would think I should be held accountable for my actions.

Is there not a parallel here?

 

Ed

 

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Posted by BaltACD on Friday, July 13, 2018 12:29 PM

7j43k
Hypothetical:

If I drive a car I'm not used to down a road I hardly know on a dark and stormy night, and I arrive at a curve too fast, swerve, and kill two pedestrians, would it be a surprise if I was charged with manslaughter?  Or would I walk?

I suspect the district attorney would think I should be held accountable for my actions.

Is there not a parallel here? 

Ed

Minimal parallel - you are driving a line of sight vehicle.  Trains at track speed are not line of sight vehicles.  You were not 'qualified' by a 'responsible' authority concerning your abilities to operate safely on that particular stretch of road.

Your drivers license equates to the engineers certification card in that both of you have been certified to operate the vehicles covered by the certification.  However, in railroading a certified engineer must ALSO be QUALIFIED on the specific territory(s) the  engineer is permitted and/or required to operate upon.  Drivers do not obtain anything like a engineers qualification to operate on any individual road, street or highway.

The Engineer will be dealt with in a manner that befits the situation.  Amtrak management also needs to be dealt with for qualifying individuals on the 'new route' that were not in fact QUALIFIED.

         

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Posted by 243129 on Friday, July 13, 2018 3:26 PM

Poor vetting, poor training, poor supervision. This has been established early on.

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