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Amtrak Wreck in Philadelphia

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Posted by Euclid on Monday, June 13, 2016 8:53 AM

Quote from the report:

“The Amtrak engineer told investigators he could not remember what happened immediately preceding the derailment.7 Specifically, he could not explain why he increased the train’s speed to 106 mph as he approached and entered the curve at Frankford Junction where the maximum authorized speed was 50 mph. His last memory until the time of the accident was at the end of the radio conversation (about 9:19 p.m.) between the disabled SEPTA train engineer and the dispatcher as he negotiated the right-hand curve preceding the derailment.”

 

If I am not mistaken, that was not his last memory.  In the interview, he remembered his process of final acceleration just before the fatal curve.   

 

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Posted by Dakguy201 on Monday, June 13, 2016 8:49 AM

I read the report.  It contained little new information on the crash other than dismissing the idea that the crashed engine had been hit by an object (rock?) prior to the crash.  Another train was stopped nearby awaiting medical help for an engineer who had been rocked.  The radio conversations regarding that situation certainly were a factor in the loss of concentration on Amtrak 188.

However, I was struck by the lack of a really coordinated response on the part of the City.  Specifically, apparently it is the practice there that police vehicles and personnel frequently are used for casualty transport, even though trained EMS personnel may be enroute.  Apparently this occured here without any real central coordination.  One result was that a trauma center (Temple) overloaded while others nearly as close went unused.    

This long after 9-11, I thought that problems of command and coordination in a major disaster had been ironed out, especially in our major cities.  Sadly, that is not true. 

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Posted by Overmod on Saturday, June 11, 2016 10:33 PM

daveklepper
And I believe a third theory still has validity, momentary loss of consciousness.

Dave, they specifically threw that theory out:

3.1 Findings

1. None of the following was a factor in this accident: the mechanical condition of the train; a foreign object striking the locomotive; the condition of the track; the weather; medical conditions of the Amtrak engineer; alcohol, other drugs, or any other type of impairment; cell phone use; and fatigue.

2. The Amtrak engineer initially accelerated his train to a high rate of speed in a manner consistent with how he habitually manipulated the controls when accelerating to a target speed, suggesting that he was actively operating the train rather than incapacitated moments before the accident.

 Weener, in his separate statement, said

... humans are inherently fallible. Even with the best training, medical screening, and hours of service prohibitions, anything from an undiagnosed medical condition to a poor night’s sleep to some external stress can result in a temporary, partial or complete loss of awareness or even consciousness. Such occurrences are eventualities, not mere possibilities...

so they were, I think, aware of the loss-of-consciousness theory and considered it carefully before dismissing it. 

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Posted by Overmod on Saturday, June 11, 2016 10:26 PM

schlimm

And there it is:  Not caused by terrorists or rock throwers (directly). And PTC could have prevented this.

And according to them, so could the system installed in the Thirties by PRR.

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Posted by Overmod on Saturday, June 11, 2016 10:17 PM

wanswheel
The polished and published final, final report

http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1602.pdf

And just as a reminder:

"For more detailed background information on this report, visit http://www.ntsb.gov/investigations/dms.html and search for NTSB accident ID DCA15MR010."

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Posted by schlimm on Saturday, June 11, 2016 7:58 PM

And there it is:  Not caused by terrorists or rock thowers (directly). And PTC could have prevented this.

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Posted by wanswheel on Saturday, June 11, 2016 5:30 PM

The polished and published final, final report

http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1602.pdf

 

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Posted by wanswheel on Thursday, May 26, 2016 10:34 AM

Stephen M. Jenner, the NTSB guy who explained it on the webcast, called it “prospective memory.”

http://www.psych.wustl.edu/learning/McDaniel_Lab/Prospective_Memory.html

 

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Posted by daveklepper on Thursday, May 26, 2016 9:28 AM

And I believe a third theory still has validity, momentary loss of consousness.

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Posted by Euclid on Thursday, May 26, 2016 9:16 AM

dehusman
Euclid [said]
However, the NTSB has also speculated that the engineer suffered memory loss that was caused by the radio transmission, and therefore in effect during the approach to the curve. The NTSB said that memory loss might be responsible for causing the derailment by causing the engineer to forget where he was in the territory
 
Euclid [said]
So we clearly have two different theories that explain the engineer’s claim of memory loss from his perspective after the wreck.

"WE" don't have two different theories, "YOU" have two different theories.  WE who understand the difference between memory loss and distraction don't have two theories.

Dave,

You need to review what the NTSB said.  There are two theories exactly as I said there were.  Both involve memory loss.  With the theory pertaining to events prior to the derailment, the NTSB referred to three different effects of hearing the radio transmission.  One was distraction. 

The NTSB then said that the distraction may have caused the engineer to lose situational awareness of where he was.  I think it is reasonable to say that is an act of forgetting.

The NTSB then also said that even if the engineer knew where he was, the distraction of the radio transmission may have cause him to FORGET his next task.

So we have the following factors:

  1. Distraction

  2. Loss of situational awareness (FORGETTING where he was)

  3. FORGETTING to perform his task.

Items #2 and #3 are an effect of item #1, and item #1 is an effect of hearing the radio transmission.   

The NTSB said this:

 

“THE SAFETY BOARD HAS INVESTIGATED AVIATION AND RAILROAD ACCIDENTS WHERE EXPERIENCED CREWS FORGOT TO PERFORM ROUTINE PROCEDURES, IN PART DUE TO INTERRUPTIONS. AS PREVIOUSLY DISCUSSED, THE ENGINEER'S PROLONGED ATTENTION TO THE SEPTA TRAIN MAY HAVE CAUSED HIM TO LOSE SITUATIONAL AWARENESS OF WHERE HE WAS. BUT EVEN IF HE KNEW WHERE HE WAS, THIS INTERRUPTION MAY HAVE CAUSED HIM TO FORGET HIS NEXT TASK, WHICH WAS TO OPERATE THE TRAIN AFTER TRAVELING AROUND THE RIGHT CURVE BEFORE THE DERAILMENT AT NO MORE THAN 80 MILES PER HOUR AND SLOW HIS TRAIN FOR THE UPCOMING CURVE AT FRANKFORD JUNCTION.”

 

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Posted by daveklepper on Thursday, May 26, 2016 8:57 AM

And the report makes no mention of the hole in the windshield,  Memory loss could have occured from the shock of the projectile of some sort hitting the windshield, regardless of whether or not it conctacted any part of the engineer's body.  And, as I noted earlier, recovery of some memory is possible and need not represent any false initial testemony.

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Posted by dehusman on Thursday, May 26, 2016 8:33 AM

Euclid
However, the NTSB has also speculated that the engineer suffered memory loss that was caused by the radio transmission, and therefore in effect during the approach to the curve. The NTSB said that memory loss might be responsible for causing the derailment by causing the engineer to forget where he was in the territory

That's not what they said.  They said he was distracted.  Memory loss is the inability to remember, distraction is loss of focus.  Two completely differnt things.  Memory loss is you can't recall the past, distraction is that you lose track of where you are in the present.

Euclid
So we clearly have two different theories that explain the engineer’s claim of memory loss from his perspective after the wreck.

"WE" don't have two different theories, "YOU" have two different theories.  WE who understand the difference between memory loss and distraction don't have two theories.

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Posted by Euclid on Thursday, May 26, 2016 8:17 AM

schlimm
It is not at all unusual for people who get shaken up in an accident to have transient retrograde amnesia, often partial and for a limited period of time preceding the trauma.   That may be true for Bastian but I do not know that with any certainty as I did not examine him. I believe I proposed that possibility within days after the derailment.  And to be clear, that is not a cause of his error, only a sequella.

After the accident, the engineer claimed to have no memory of the events since leaving the last station prior to the curve.  Therefore, memory loss as a sequela induced by the derailment seems entirely plausible.  Of course, that memory loss, as a sequela that was caused only by the effect of the derailment, cannot have caused the derailment.

However, the NTSB has also speculated that the engineer suffered memory loss that was caused by the radio transmission, and therefore in effect during the approach to the curve.  The NTSB said that memory loss might be responsible for causing the derailment by causing the engineer to forget where he was in the territory.

So we clearly have two different theories that explain the engineer’s claim of memory loss from his perspective after the wreck. 

  1. A theory says that reported memory loss was only an effect of the wreck and not the cause of it.

     

  2. A theory says that the reported memory loss was the cause of the wreck and not the effect of it.

 

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Posted by schlimm on Thursday, May 26, 2016 6:46 AM

greyhounds

 

 
schlimm

 

 
 

It is not at all unusual for people who get shaken up in an accident to have transient retrograde amnesia, often partial and for a limited period of time preceding the trauma.   That may be true for Bastian but I do not know that with any certainty as I did not examine him. I believe I proposed that possibility within days after the derailment.  And to be clear, that is not a cause of his error, only a sequela.

 

 

 

Definition of sequela

plural sequelae play\-ˈkwe-(ËŒ)lÄ“\

  1. 1:  an aftereffect of a disease, condition, or injury

  2. 2:  a secondary result

 

Exactly!  Thanks.

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Posted by greyhounds on Wednesday, May 25, 2016 11:16 PM

schlimm

 

 
 

It is not at all unusual for people who get shaken up in an accident to have transient retrograde amnesia, often partial and for a limited period of time preceding the trauma.   That may be true for Bastian but I do not know that with any certainty as I did not examine him. I believe I proposed that possibility within days after the derailment.  And to be clear, that is not a cause of his error, only a sequella.

 

Definition of sequela

plural sequelae play\-ˈkwe-(ËŒ)lÄ“\

  1. 1:  an aftereffect of a disease, condition, or injury

  2. 2:  a secondary result

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Posted by schlimm on Tuesday, May 24, 2016 4:10 PM

wanswheel

More old news from February, excerpt from Law360

http://www.law360.com/articles/753272/amtrak-document-release-puts-focus-on-engineer

When first interviewed by the NTSB on May 15, Bostian was extremely hazy in his recollection of the events leading up to the derailment. But when interviewed again on Nov. 10, he acknowledged accelerating, along with pulling the brake once the train was in the curve.

“His change of testimony in this case is extraordinary,” said Bob Mongeluzzi... calling it a “red flag.”

“It's important to the people who lost loved ones and to the people who were catastrophically injured and suffer to this day, because one of the things they want is to try to know what happened,” he added. “When you have the chief culprit on the other side changing his story, that's a devastating insult to these people who are already devastatingly injured.”

 

 

It is not at all unusual for people who get shaken up in an accident to have transient retrograde amnesia, often partial and for a limited period of time preceding the trauma.   That may be true for Bastian but I do not know that with any certainty as I did not examine him. I believe I proposed that possibility within days after the derailment.  And to be clear, that is not a cause of his error, only a sequella.

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Posted by Euclid on Tuesday, May 24, 2016 3:11 PM

RME,

I only listen to what a source says and consider its plausibility.  I never believe a source simply based on the assumption of objectivity.  In this particular case, you seem intent on interpreting my comments as bashing Bostian.  But my actual point is to question the practice of forgiving a rules violation as being a sort of honest mistake.  I have never heard of that being done before in the railroad industry.   

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Posted by RME on Tuesday, May 24, 2016 2:42 PM

wanswheel
I've been damned with praise.

It was the context.  Yes, it's important to note that Bostian's story has been "evolving" -- and how the details have changed, whether the result looks like it has CYA of some kind involved, etc.

The problem is that hearing it from a plaintiff's attorney, even absent the usual sort of manipulation of the truth one gets in lawyers' rhetoric so often, is unlikely to be objective.  Since Euclid in particular often takes sources as objective that are likely highly biased, it was a dangerous thing at best to frame the "discovery" of the evolving disparities in those particular words.

I confess that I'm glad I don't have to evaluate whether or not Bostian was or is telling the whole truth about what he does and doesn't remember clearly.  The real issue we discussed for so long is whether he was physically incapacitated in some way before the accident, and the great preponderance of the current evidence, as well as his 'emergent' memory, indicates that he was not.

I still think he gets points for blowing the horn to warn any yard workers even as the train was derailing.

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Posted by daveklepper on Tuesday, May 24, 2016 1:39 PM

Uh Uh....   Several times since moving to Israel I have been questioned as a witness to some thankfully minior and non-injuring event.  I told the investigators what I knew and remembered accurately, but omitted matrial that I had forgotton but later rememgered as scenes returned to memory, and so I tried and was usually successful to amend the reccord with the addiitonal information.

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Posted by Euclid on Tuesday, May 24, 2016 1:33 PM

wanswheel

http://www.law360.com/articles/753272/amtrak-document-release-puts-focus-on-engineer

When first interviewed by the NTSB on May 15, Bostian was extremely hazy in his recollection of the events leading up to the derailment. But when interviewed again on Nov. 10, he acknowledged accelerating, along with pulling the brake once the train was in the curve.

“His change of testimony in this case is extraordinary,” said Bob Mongeluzzi... calling it a “red

 

I would just consider the statement itself rather than reject it because of who said it. I too was surprised to read that interview of the engineer where he seemed to recall a lot of details after we had been told that he recalled nothing since leaving the last station.  I lieu of any explanation for the discrepancy, I conclude that the original claim of recalling nothing was untrue.  In particular, I believe the engineer was trying to have it both ways by remembering details for the interview and saying that the memory was dreamlike. 

 

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Posted by wanswheel on Tuesday, May 24, 2016 12:56 PM

I've been damned with praise.

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Posted by RME on Tuesday, May 24, 2016 12:54 PM

Just as a note, I consider providing any quote from a plaintiff's attorney as though it were an objective topic for discussion little better than trolling.  Even considering the general veracity and worth of the poster.

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Posted by wanswheel on Tuesday, May 24, 2016 12:50 PM

More old news from February, excerpt from Law360

http://www.law360.com/articles/753272/amtrak-document-release-puts-focus-on-engineer

When first interviewed by the NTSB on May 15, Bostian was extremely hazy in his recollection of the events leading up to the derailment. But when interviewed again on Nov. 10, he acknowledged accelerating, along with pulling the brake once the train was in the curve.

“His change of testimony in this case is extraordinary,” said Bob Mongeluzzi... calling it a “red flag.”

“It's important to the people who lost loved ones and to the people who were catastrophically injured and suffer to this day, because one of the things they want is to try to know what happened,” he added. “When you have the chief culprit on the other side changing his story, that's a devastating insult to these people who are already devastatingly injured.”

 

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Posted by RME on Tuesday, May 24, 2016 11:37 AM

schlimm
Negligent homicide or involuntary manslaughter might apply.

The former would be far more likely.  A parallel might be found in the case of Megabus driver Tomaszewski, who ran the bus under a low overpass while tinkering with his GPS to figure out where he was.

There's always a potential issue of politically-driven use of 'criminal' charges by prosecutors.  I'm intentionally not going there, just pointing out a previous example that seems to share some common characteristics.

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Posted by wanswheel on Tuesday, May 24, 2016 11:37 AM

The city won't prosecute him, not after Mayor Nutter declared him guilty. But he's still a defendant in civil lawsuits.

Old news from Philly .com, Feb. 10

http://articles.philly.com/2016-02-10/business/70483588_1_ntsb-amtrak-train-national-transportation-safety-board

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Posted by Euclid on Tuesday, May 24, 2016 11:36 AM

RME
 
Euclid
Is he now considered to be just one more victim of the derailment, the same as the others who were killed or injured?

 

Are you considering that demonizing him, or blaming him, or agitating to put him in the pokey or soak him for 'large money damages', is accomplishing anything?

He will be found accountable in the proper ways available to the legal system, and given whatever stringency or mercy that system affords him.  It only makes us look smaller and more vindictive to call for more than that.

 

I am not calling for anything.  I could not care less whether any punishment is directed to Bostian.  I am just trying to understand how the railroads in general look at this type of issue. 

They have rules forbidding everything that can possibley go wrong, and yet most of what can go wrong could be caused by distraction.  On the face of it, distraction itself cannot be prevented.  So if somebody violates a rule due to being distracted, they cannot be blamed for violating the rule.  Yet, I don't believe the railroad industry looks at it that way.   

Certainly in a disaster like this, everyone wants to know who is responsible for it.  The way this NTSB conclusion has been rolled out, it sounds like nobody is responsible.  It is like an act of God.  So I would like a little clarity on this point.

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Posted by schlimm on Tuesday, May 24, 2016 11:24 AM

BaltACD

 

 
Euclid

About a year ago, right after the crash, there was lots of news on the topic of whether the engineer would be prosecuted.  Now, in the wake of this latest information from the NTSB, I find no such news.  I am just trying to understand the exact terms of the conclusion about the engineer being distracted.  Is he now considered to be just one more victim of the derailment, the same as the others who were killed or injured?

http://www.cnn.com/2015/05/20/opinions/jackson-criminal-case-amtrak-crash/

 

For Criminal prosecution there needs to be Criminal Intent.

Where is the Criminal Intent in Bostains actions or inactions?  How would Bostain benefit from his actions or inactions?

 

Negligent homicide or involuntary manslaughter might apply.

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Posted by BaltACD on Tuesday, May 24, 2016 11:19 AM

Euclid

About a year ago, right after the crash, there was lots of news on the topic of whether the engineer would be prosecuted.  Now, in the wake of this latest information from the NTSB, I find no such news.  I am just trying to understand the exact terms of the conclusion about the engineer being distracted.  Is he now considered to be just one more victim of the derailment, the same as the others who were killed or injured?

http://www.cnn.com/2015/05/20/opinions/jackson-criminal-case-amtrak-crash/

For Criminal prosecution there needs to be Criminal Intent.

Where is the Criminal Intent in Bostains actions or inactions?  How would Bostain benefit from his actions or inactions?

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Posted by RME on Tuesday, May 24, 2016 11:04 AM

Euclid
Is he now considered to be just one more victim of the derailment, the same as the others who were killed or injured?

Are you considering that demonizing him, or blaming him, or agitating to put him in the pokey or soak him for 'large money damages', is accomplishing anything?

He will be found accountable in the proper ways available to the legal system, and given whatever stringency or mercy that system affords him.  It only makes us look smaller and more vindictive to call for more than that.

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