Poor hiring, vetting, supervision and training procedures.......

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Poor hiring, vetting, supervision and training procedures.......
Posted by 243129 on Tuesday, October 29, 2019 3:24 PM

......are not exclusive to Amtrak.

This occurred on the former N.Y. N.H. & H. mainline.

https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1905.pdf

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Posted by charlie hebdo on Tuesday, October 29, 2019 5:17 PM

Seems like poor training is not limited to Amtrak.  Boeing deliberately omitted any mention of the fatal, faulty system on the 737-Max from training manuals: profits and obscene compensation packages for executives over safety and human lives. 

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Posted by Overmod on Tuesday, October 29, 2019 5:25 PM

"Subtle cognitive impairment"

Of course, the real culprits in this accident were the idiot programmers who failed to incorporate emergent severe civil restrictions into a cab signal system.  I see this has not been fixed because they're going to 'wait for PTC to do it'.  Sure hope there isn't another problem before then!

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Posted by charlie hebdo on Tuesday, October 29, 2019 6:56 PM

Could someone please activate the link?  It's hard to do from a phone. 

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Posted by rdamon on Tuesday, October 29, 2019 7:23 PM
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Posted by charlie hebdo on Tuesday, October 29, 2019 7:35 PM
HTTP/1.1 200 OK
Server: Microsoft-IIS/7.5
Date: Wed, 30 Oct 2019 00:34:09 GMT
Connection: close
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Posted by York1 on Tuesday, October 29, 2019 7:48 PM

Someone out there doesn't want us to read it.

John       

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Posted by rdamon on Tuesday, October 29, 2019 8:43 PM

https://www.ntsb.gov/

Does the same ...  hmmm 

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Posted by Overmod on Tuesday, October 29, 2019 9:13 PM

Link as formatted in the original post worked for me this afternoon.  Like an idiot I did not save the downloaded PDF on this computer, and it disappeared just now when I tried to do so.

It's a government server problem, and I expect it will be resolved when the government gets around to it.  Link as provided will work when they do so.

What happened was a developing case of sun kink on track 3 (the most northerly track of the 4) on the Metro-North part of the old New Haven.  Several increasingly urgent calls about hard riding were checked, and increasingly rigorous slow orders issued.  Apparently at least one MU then zipped through the area at track speed, then some fellow says he outright 'forgot' about the issued slow order and went right at it doing 56mph.  He 'emergency braked' when he saw the kink, but put his train on the ground going over it.

There is some mention in the report that this wasn't considered an 'accident', perhaps because nobody died.  I'm not sure I'd concur about the importance.  "Forgetting" a 10mph emergency slow order for progressive track kink could have been almost unbelievably deadly with a full load of passengers at 55mph.

Usual excuses about sleep apnea, failure to use his CPAP, chronic diabetes but wouldn't take his meds, etc.

 

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Posted by BaltACD on Tuesday, October 29, 2019 9:24 PM

rdamon

I was able to access the report shortly after the thread was created with the cold link....what has happened since ???????????

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Posted by BaltACD on Tuesday, October 29, 2019 9:34 PM

Overmod
Link as formatted in the original post worked for me this afternoon.  Like an idiot I did not save the downloaded PDF on this computer, and it disappeared just now when I tried to do so.

It's a government server problem, and I expect it will be resolved when the government gets around to it.  Link as provided will work when they do so.

What happened was a developing case of sun kink on track 3 (the most northerly track of the 4) on the Metro-North part of the old New Haven.  Several increasingly urgent calls about hard riding were checked, and increasingly rigorous slow orders issued.  Apparently at least one MU then zipped through the area at track speed, then some fellow says he outright 'forgot' about the issued slow order and went right at it doing 56mph.  He 'emergency braked' when he saw the kink, but put his train on the ground going over it.

There is some mention in the report that this wasn't considered an 'accident', perhaps because nobody died.  I'm not sure I'd concur about the importance.  "Forgetting" a 10mph emergency slow order for progressive track kink could have been almost unbelievably deadly with a full load of passengers at 55mph.

Usual excuses about sleep apnea, failure to use his CPAP, chronic diabetes but wouldn't take his meds, etc.

100% Man Failure - that the report is trying to blame on everything except the person's admitted failure.

I don't know Metro-North's procedures.

On my carrier - with a single person operating the 'locomotive'; when a inroute Train Message (Slow Order) is issued - the train must be stopped - person operating the 'locomotive' is prohibited from 'copying the mandatory directive' (Slow Order) while the train is in motion and the Engineer's attention needs to be focused on what he is doing in operating the train.  From the report it is difficult to ascertain what procedures were used to communicate the Slow Order.  

I can't determine the sense of 'urgency' that the Engineer attached to getting the slow order - in stating that he 'forgot' it; it is evident he attached no urgency to getting it and complying with it.

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Posted by charlie hebdo on Wednesday, October 30, 2019 5:59 AM

If he is non-compliant with his disease treatments,  this should be examined more regularly as a policy. It's serious. 

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Posted by Overmod on Wednesday, October 30, 2019 8:04 AM

charlie hebdo
If he is non-compliant with his disease treatments,  this should be examined more regularly as a policy . It's serious. 

I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment.   It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance.

I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance.  The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens.  I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.)  Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons.

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Posted by BaltACD on Wednesday, October 30, 2019 8:33 AM

Overmod
 
charlie hebdo
If he is non-compliant with his disease treatments,  this should be examined more regularly as a policy . It's serious.  

I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment.   It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance.

I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance.  The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens.  I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.)  Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons.

If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'.   If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only.

The medical community expecting him to faithfully follow their recommendations is very naive.

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Posted by 243129 on Wednesday, October 30, 2019 8:57 AM

This from NTSB report RAB1905: " The New Haven Line uses an electrified third rail between Grand Central Terminal and MP 14.9 in Pelham, New York."

The third rail territory ends east of Woodlawn interlocking and west of Mount Vernon station.

 

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Posted by 243129 on Wednesday, October 30, 2019 8:59 AM

I forgot to add 'poor supervision' to the title.Oops - Sign

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Posted by Overmod on Wednesday, October 30, 2019 9:05 AM

243129
I forgot to add 'poor supervision' to the title.

Well, go back and do it, then!

Third rail is the least of their factual problems; I believe they attributed ownership on the east end, in Connecticut, to Metro-North, and I think Amtrak now owns more of the west end than the NTSB said.  This has little bearing on the actual 'controversy' addressed in the report, but it does show both sloppy research and a certain cavalier attitude in both fact-finding and fact-checking.

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Posted by charlie hebdo on Wednesday, October 30, 2019 9:07 AM

BaltACD

 

 
Overmod
 
charlie hebdo
If he is non-compliant with his disease treatments,  this should be examined more regularly as a policy . It's serious.  

I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment.   It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance.

I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance.  The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens.  I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.)  Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons.

 

If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'.   If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only.

The medical community expecting him to faithfully follow their recommendations is very naive.

 

Ultimately,  fitness for duty in civilian life depends on the company,  not the doctor, medical or psychologist, unless we are employed by that company. Amtrak needs stricter procedures. 

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Posted by 243129 on Wednesday, October 30, 2019 9:19 AM

charlie hebdo
Amtrak needs stricter procedures.

As does Metro North.

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Posted by Overmod on Wednesday, October 30, 2019 9:20 AM

charlie hebdo
Amtrak needs stricter procedures. 

This specific discussion is about Metro-North; it was a commuter train that 'went on the ground'.  It's possible that Amtrak has stricter procedures to preclude this sort of thing -- but if they don't, your point does stand.

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Posted by 243129 on Wednesday, October 30, 2019 9:28 AM

Overmod
Third rail is the least of their factual problems;

One of their many factual problems.

Overmod
I believe they attributed ownership on the east end, in Connecticut, to Metro-North,

The state of Connecticut owns from New Haven to the New York state line at Greenwich/Portchester.

Overmod
and I think Amtrak now owns more of the west end than the NTSB said.

Amtrak territory begins from Chapel Street New Haven and east.

Overmod
sloppy research and a certain cavalier attitude in both fact-finding and fact-checking.

Which is becoming more and more prevalent at NTSB.

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Posted by 243129 on Wednesday, October 30, 2019 9:33 AM

Track #3 should have been removed from service not speed restricted.

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Posted by charlie hebdo on Wednesday, October 30, 2019 10:09 AM

Overmod

 

 
charlie hebdo
Amtrak needs stricter procedures. 

 

This specific discussion is about Metro-North; it was a commuter train that 'went on the ground'.  It's possible that Amtrak has stricter procedures to preclude this sort of thing -- but if they don't, your point does stand.

 

Metro North and any railroad need systematic procedures to check on operating personnel with conditions that could impair their performance.  They check on substances,  but these factors are at least as important. 

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Posted by York1 on Wednesday, October 30, 2019 10:45 AM

This is from a website that pertains to commercial pilot training and licensing (not an official pilot-licensing site) :

 

"After the initial issue, you are required to attend a medical assessment on an annual basis until the age of forty, then every six months until the age of 65 which is the age at which class one medical privileges are revoked. Items such as ECG and audiograms are retested at periodic intervals, increasing in frequency with age."

 

https://www.flightdeckfriend.com/become-an-airline-pilot/airline-pilot-medical-requirements/

 

I know the age requirement for commericial pilots was changed from 60 to 65 not too many years ago.

John       

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Posted by charlie hebdo on Wednesday, October 30, 2019 10:59 AM

ADHD (a major cause of inattention)  is  no longer diagnosed by physicians alone,  though they prescribe meds if the diagnosis is made.  They depend on a thorough neuropsych evaluation using a variety of tests.  Unless FAA regs have changed,  they do not permit pilots to use prescribed stimulant medication for ADHD.  I'm not clear what the FRA position is. 

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Posted by BaltACD on Wednesday, October 30, 2019 12:33 PM

charlie hebdo
 
BaltACD 
Overmod 
charlie hebdo
If he is non-compliant with his disease treatments,  this should be examined more regularly as a policy . It's serious.  

I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment.   It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance.

I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance.  The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens.  I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.)  Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons. 

If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'.   If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only.

The medical community expecting him to faithfully follow their recommendations is very naive. 

Ultimately,  fitness for duty in civilian life depends on the company,  not the doctor, medial or psychologist, unless we are employed by that company. Amtrak needs stricter procedures. 

Company doctors examine employees fitness for duty, their decisions may be different than one's own personal doctor.  Company doctors are the final authority.

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Posted by 243129 on Thursday, October 31, 2019 7:53 AM

Two trains in a row 'blew' that speed restriction.  Why?

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Posted by charlie hebdo on Thursday, October 31, 2019 9:52 AM

How were the speed restrictions communicated?  By dispatchers?  Perhaps the system is faulty? 

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Posted by Overmod on Thursday, October 31, 2019 11:01 AM

charlie hebdo
How were the speed restrictions communicated?

They describe the procedure in the report. 

The problem, again, is in a paper system that is both inadequately communicated and inadequately back-checked for compliance.

In 'the old days' on this specific part and perhaps this specific track of the New Haven, an emergency civil slow order for sun kink or other rapidly-developing track-geometry problem would probably have required the recipient to read it back word-for-word to 'show understanding' as well as confirm receipt.  We could argue whether rote recitation is different from 'confirming the sense in one's own words', but in any case the order didn't make enough 'impression' on the engineer concerned to be memorable.

The fact that another train blew through the restriction a couple of hours earlier may be suggestive that the wording of the order didn't adequately confirm either the importance of the restriction or the specific nature of the problem as both evolving and severe.  Perhaps the fact of it being a "10mph" slow order on a congested and very busy 70mph railroad at a significant traffic time was thought to be enough.  I do have to wonder if there are so many lackadaisical readers on Metro-North's boards that ignorance lightning could strike twice for the same order.

I do note that the report is silent on what the reason for the earlier train's 'speeding' turned out to be.  I'd be flat astounded that the Government boys weren't on that train number like hounds to the chase, and had that engineer in 'interviews' within hours...

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Posted by 243129 on Thursday, October 31, 2019 11:09 AM

charlie hebdo
How were the speed restrictions communicated? By dispatchers?

This restriction was added to the Daily Train Operations Bulletin Order (DTOBO) as it was recently discovered. The engineer(s) did not follow protocol as is in evidence by his testimony.

"During the station stop, the engineer stated in his postaccident interview that he communicated with the RTC and received a Line C (speed restrictions received en route) to add to his Daily Train Operations Bulletin Order (DTOBO).15 The Line C information issued to the train engineer was for a speed restriction of 10 mph that extended from catenary pole 214 to catenary bridge 216, which are located between the Port Chester and Rye Train Stations. Metro-North Operating Rules (section 3, rule A, part 2) required the train engineer to communicate the Line C speed restriction to the train conductor. This action is to aid train engineers so that train conductors can remind them of approaching speed restrictions. The train engineer told investigators that he did not communicate the Line C speed restriction instructions to the train conductor."

Within the space of less than one hour this engineer(1373), also the previous engineer(1371), forgot a speed restriction with a reduction of 50 MPH in speed!?

My mantra no matter how annoying some may find it comes in to play here.

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