Trains.com

Amtrak Wreck in Philadelphia

69567 views
1561 replies
1 rating 2 rating 3 rating 4 rating 5 rating
  • Member since
    July 2006
  • 9,610 posts
Posted by schlimm on Friday, May 20, 2016 9:23 PM

Norm48327

 

 
zugmann
Now who is the one with a theatrical performance with an investigative theme combined with a political agenda?

Of course the NTSB has an agenda. Everyone does. And the NTSB has always been transparent about it (their top 10 most wanted safety improvements list). But let me ask you, Euclid: why should we take what you (just another anonymous forum poster with unknown experience) say over that what the NTSB says? I'm not trying to be negative; just curious. You have an agenda, too and are pretty transparent with it as well. So, what makes your agenda better than theirs? You aren't afraid to completely trash the NTSB, yet we should consider your thoughts? Why? I mean, accusing the investigators of not even looking at the windshield is pretty damned ballsy.

 

Thumbs Up Thumbs Up

Two posters here can't admit there may be people who know more than they do. They know who they are.

 

Given that one,  I agree with Husman and Zugmann's contentions, and two, you seldom offer anything but snide, uninformed comments and insults, the conclusion must be that since "Two posters here can't admit there may be people who know more than they do," one of them is Euclid and the other is you.

C&NW, CA&E, MILW, CGW and IC fan

  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Friday, May 20, 2016 2:55 PM

zugmann

 

 
Euclid
But going after rocking would step on toes of those run cities where rocking occurs.

 

 

Now who is the one with a theatrical performance with an investigative theme combined with a political agenda?

Of course the NTSB has an agenda.  Everyone does.  And the NTSB has always been transparent about it (their top 10 most wanted safety improvements list).  But let me ask you, Euclid:  why should we take what you (just another anonymous forum poster with unknown experience) say over that what the NTSB says?  I'm not trying to be negative; just curious.  You have an agenda, too and are pretty transparent with it as well.  So, what makes your agenda better than theirs?   You aren't afraid to completely trash the NTSB, yet we should consider your thoughts?  Why? I mean, accusing the investigators of not even looking at the windshield is pretty damned ballsy.

 

 

 

 

 

What is my agenda?  I am just curious.  As far as believing that the FBI never looked at the windshield, that is just my opinion.  You may think it is damned balsy, but I think about the same of Sumwalt's rejection of the possibility of gunshots the day before the FBI is sheduled to check into that possibility with their expertise.   

You ask why you should take what I say over what the NTSB says.  You should do that only if you think what I say makes more sense.  It is your choice.

  • Member since
    May 2003
  • From: US
  • 25,054 posts
Posted by BaltACD on Friday, May 20, 2016 2:11 PM

Norm48327
zugmann
Now who is the one with a theatrical performance with an investigative theme combined with a political agenda?

Of course the NTSB has an agenda. Everyone does. And the NTSB has always been transparent about it (their top 10 most wanted safety improvements list). But let me ask you, Euclid: why should we take what you (just another anonymous forum poster with unknown experience) say over that what the NTSB says? I'm not trying to be negative; just curious. You have an agenda, too and are pretty transparent with it as well. So, what makes your agenda better than theirs? You aren't afraid to completely trash the NTSB, yet we should consider your thoughts? Why? I mean, accusing the investigators of not even looking at the windshield is pretty damned ballsy.

Thumbs Up Thumbs Up

Two posters here can't admit there may be people who know more than they do. They know who they are.

There are many that know more than I do....those that believe the NTSB doesn't have it's own political agenda above and beyond attempting to portray facts, are not among them.

Never too old to have a happy childhood!

              

  • Member since
    December 2007
  • From: Southeast Michigan
  • 2,983 posts
Posted by Norm48327 on Friday, May 20, 2016 1:21 PM

zugmann
Now who is the one with a theatrical performance with an investigative theme combined with a political agenda?

Of course the NTSB has an agenda. Everyone does. And the NTSB has always been transparent about it (their top 10 most wanted safety improvements list). But let me ask you, Euclid: why should we take what you (just another anonymous forum poster with unknown experience) say over that what the NTSB says? I'm not trying to be negative; just curious. You have an agenda, too and are pretty transparent with it as well. So, what makes your agenda better than theirs? You aren't afraid to completely trash the NTSB, yet we should consider your thoughts? Why? I mean, accusing the investigators of not even looking at the windshield is pretty damned ballsy.

Thumbs Up Thumbs Up

Two posters here can't admit there may be people who know more than they do. They know who they are.

Norm


  • Member since
    December 2007
  • From: Southeast Michigan
  • 2,983 posts
Posted by Norm48327 on Friday, May 20, 2016 1:16 PM

schlimm

 

 
Norm48327

 

 
schlimm
You seriously think the FBI is still investigating a rocking, if they ever were?

 

I guess life in academia's ivory tower is different than that of the real world.

 

 

 

Perhaps instead of a snide and rather predictable ad hominem insult, why not answer the substantive question?  

 

Because you know the answer and simply want to argue.

Norm


  • Member since
    December 2001
  • From: Northern New York
  • 24,924 posts
Posted by tree68 on Friday, May 20, 2016 1:09 PM

wanswheel
I wonder if the punk who aimed his rock just right has a conscience, and keeps up with the news enough to believe he has blood on his hands.

Heck, it probably gives him braggin' rights...  Angry

LarryWhistling
Resident Microferroequinologist (at least at my house) 
Everyone goes home; Safety begins with you
My Opinion. Standard Disclaimers Apply. No Expiration Date
Come ride the rails with me!
There's one thing about humility - the moment you think you've got it, you've lost it...

  • Member since
    January 2002
  • From: Canterlot
  • 9,538 posts
Posted by zugmann on Friday, May 20, 2016 12:26 PM

Euclid
But going after rocking would step on toes of those run cities where rocking occurs.

 

Now who is the one with a theatrical performance with an investigative theme combined with a political agenda?

 



 

Of course the NTSB has an agenda.  Everyone does.  And the NTSB has always been transparent about it (their top 10 most wanted safety improvements list).  But let me ask you, Euclid:  why should we take what you (just another anonymous forum poster with unknown experience) say over that what the NTSB says?  I'm not trying to be negative; just curious.  You have an agenda, too and are pretty transparent with it as well.  So, what makes your agenda better than theirs?   You aren't afraid to completely trash the NTSB, yet we should consider your thoughts?  Why? I mean, accusing the investigators of not even looking at the windshield is pretty damned ballsy.

 

 

 

  

The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.

  • Member since
    November 2005
  • 4,190 posts
Posted by wanswheel on Friday, May 20, 2016 10:50 AM

Euclid

The agenda here could have just as well been finding ways to protect crews from rocking.    

Sounds reasonable, considering the SEPTA incident was the sine qua non to the crash. I wonder if the punk who aimed his rock just right has a conscience, and keeps up with the news enough to believe he has blood on his hands.

  • Member since
    July 2006
  • 9,610 posts
Posted by schlimm on Friday, May 20, 2016 10:19 AM

Norm48327

 

 
schlimm
You seriously think the FBI is still investigating a rocking, if they ever were?

 

I guess life in academia's ivory tower is different than that of the real world.

 

Perhaps instead of a snide and rather predictable ad hominem insult, why not answer the substantive question?  

C&NW, CA&E, MILW, CGW and IC fan

  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Friday, May 20, 2016 8:02 AM

zugmann

Euclid

There is no reason to go beyond the obvious, which is the failure to control speed. I will be surprised if the engineer is vilified, as you say.

But that is what the NTSB does.  They go beyond the obvious to find the events that led up to the accident.  Otherwise, they wouldn't be needed.  Any moron with no experience/expertise can easily say "he durn was goin' too fast and went kerash!"

 
Yes, they do that, and in doing so, they go beyond the finding of fact and into speculation in order to highlight a select cause that calls for changes in the industry.  I do not see this as an objective, legal investigation such as a criminal investigation or even a railroad management investigation.  I regard NTSB investigations as a kind of theatrical performance with an investigative theme combined with a political agenda.
 
In this case, the agenda is distraction in a variety that goes beyond the obvious of electronic devices, and into an area of endless threat of endangerment.  Where does that end?  Now the whole job is distracting.  Now the remedy will be in finding ways to tone down sources of distraction, and somehow stiffen employees to become distraction-resistant.  The mission will open doors to massive R&D by outside contractors and consultants.

The agenda here could have just as well been finding ways to protect crews from rocking.  After all, this incident proves that rocking is so serious that engineers can lose control of their train just hearing about it.  But going after rocking would step on toes of those run cities where rocking occurs.     

  • Member since
    September 2003
  • From: Omaha, NE
  • 10,619 posts
Posted by dehusman on Friday, May 20, 2016 7:55 AM

I guess life in academia's ivory tower is different than that of the real world.

Nope, loss of situational awareness is the real world.  There has been a rule in real railroad rule books to cover such a situation for decades.

At a train meet when a brakeman lines the switch for the opposing train, he is supposed to cross over the tracks to the opposite side away from the switch stand.  That's because there were dozens of times when he would line the switch, then a few moments later see the approaching train, not remember whether he had lined the switch and then re-line the switch, putting the opposing train right into his train.

It happens.  Track inspectors get time on main 1 to go west and put on main 2 and head east.  Trains tell the dispatcher they are at the north switch when they are at the south switch, people think they are at one station when they are at the next.  I have seen or read of dozens of such incidents over the last 3 decades.  It happens. Numerous collisions and accidents.  Never one where the crew got rocked and were incapacitated.

Dave H. Painted side goes up. My website : wnbranch.com

  • Member since
    December 2001
  • From: Northern New York
  • 24,924 posts
Posted by tree68 on Friday, May 20, 2016 7:49 AM

Euclid
I feel that blaming the engineer’s failure to do that on a source of distraction is an attempt to provide the engineer with an excuse out of sympathy.

No - if distraction is an issue, then it's necessary to determine the source of the distraction and find ways to reduce/eliminate it as a factor in the future.  That's how accident prevention works.  

It may be found, when all is said and done, that the engineer's actions (or lack thereof) were an "honest mistake."  Mitigating circumstances and all that.

As with most such incidents, there are a variety of factors involved.  Distraction and the lack of a system to slow the train (be it a low-tech sign or a high-tech warning system) appear to be two major factors here.

Other factors come into play as well - some are fixable, some aren't.  The New York Central moved a river to somewhat straighten out a curve after a major derailment was laid partially to the sharpness of said curve (train handling was the other factor).

You certainly come across as having an agenda here.

LarryWhistling
Resident Microferroequinologist (at least at my house) 
Everyone goes home; Safety begins with you
My Opinion. Standard Disclaimers Apply. No Expiration Date
Come ride the rails with me!
There's one thing about humility - the moment you think you've got it, you've lost it...

  • Member since
    December 2007
  • From: Southeast Michigan
  • 2,983 posts
Posted by Norm48327 on Friday, May 20, 2016 7:08 AM

schlimm
You seriously think the FBI is still investigating a rocking, if they ever were?

I guess life in academia's ivory tower is different than that of the real world.

Norm


  • Member since
    January 2002
  • From: Canterlot
  • 9,538 posts
Posted by zugmann on Thursday, May 19, 2016 11:40 PM

Euclid
There is no reason to go beyond the obvious, which is the failure to control speed. I will be surprised if the engineer is vilified, as you say.

 

But that is what the NTSB does.  They go beyond the obvious to find the events that led up to the accident.  Otherwise, they wouldn't be needed.  Any moron with no experience/expertise can easily say "he durn was goin' too fast and went kerash!"

 

 

 

 

  

The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.

  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Thursday, May 19, 2016 10:43 PM

Dave,

Ostensibly, the FBI was called in to investigate whether or not the windshield damage was caused by a gun shot.  One or two days earlier, Sumwalt said he wanted to dismiss the possibility of gun shots. Next, the FBI provided Sumwalt with his desired dismissal.  I doubt they ever looked at the windshield. 

I have no problem with the theory now offered by the NTSB about the cause, except I believe they are going too far to suggest that the ultimate cause was distraction.  In the Schanoes blog, he says that engineers are responsible to control the speed of their train, and there are no excuses.  I feel that blaming the engineer’s failure to do that on a source of distraction is an attempt to provide the engineer with an excuse out of sympathy.  Reaching that far has no place in an objective accident investigation.  There is no reason to go beyond the obvious, which is the failure to control speed.  I will be surprised if the engineer is vilified, as you say.    

  • Member since
    September 2003
  • From: Omaha, NE
  • 10,619 posts
Posted by dehusman on Thursday, May 19, 2016 10:25 PM

Norm48327
Not really making any assumption, Dave. Just saying there may be information the FBI does not want published if (and that's a big if) they have begun a criminal investigation as a result of their findings on the windshield. No conspiracy theory either. It's just the way law enforcement sometimes works. They will not make public things known only to the criminal.

So your theory is that the NTSB public released a finding they know is wrong and that a couple years from now they we hold another press coference and tell us they were just joshing us, that the real reason for the crash was a rock throwing incident, after there have been several years of litigation by the victims and after the engineer has been villified in the press and witness stand based on the original report.

Right.

That's not the way the NTSB works any time.

Dave H. Painted side goes up. My website : wnbranch.com

  • Member since
    July 2006
  • 9,610 posts
Posted by schlimm on Thursday, May 19, 2016 8:45 PM

Norm48327
Not really making any assumption, Dave. Just saying there may be information the FBI does not want published if (and that's a big if) they have begun a criminal investigation as a result of their findings on the windshield. No conspiracy theory either. It's just the way law enforcement sometimes works. They will not make public things known only to the criminal.

You seriously think the FBI is still investigating a rocking, if they ever were?

C&NW, CA&E, MILW, CGW and IC fan

  • Member since
    December 2007
  • From: Southeast Michigan
  • 2,983 posts
Posted by Norm48327 on Thursday, May 19, 2016 5:14 PM

dehusman

 

 
Norm48327
So, presumably, the windshield was inspected at the FBI labs and they said it was not a bullet.  That conclusion would most likely lead to a rock damaging the windshield.

 

Why does everybody assume that the only thing that can hit a windshield is a rock?  The engine obviously struck many things on its path after it left the rails (the entire engineer's side is scraped up, as is the nose.)  Lets say to scrape up the side it had to hit a catenary pole.  Its it not in the realm of possibility that something on the catenary pole hit the windshield? (ladder, sign, bracket, etc.)  There is ample evidence the engine hit stuff after it derailed.  There is ample evidence the stuff it hit disfigured the front and sides of the engine. 

There is zero evidence that something was thrown at the windshield.  Has ANY official report, FBI or NTSB, said that the windhsield was hit by a rock BEFORE the train derailed?

Why is it so hard to accept that the damage to the engine happened after the engine derailed?

 

Not really making any assumption, Dave. Just saying there may be information the FBI does not want published if (and that's a big if) they have begun a criminal investigation as a result of their findings on the windshield. No conspiracy theory either. It's just the way law enforcement sometimes works. They will not make public things known only to the criminal.

Norm


  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Thursday, May 19, 2016 4:45 PM

dehusman

 

 
Norm48327
So, presumably, the windshield was inspected at the FBI labs and they said it was not a bullet.  That conclusion would most likely lead to a rock damaging the windshield.

 

Why does everybody assume that the only thing that can hit a windshield is a rock?  The engine obviously struck many things on its path after it left the rails (the entire engineer's side is scraped up, as is the nose.)  Lets say to scrape up the side it had to hit a catenary pole.  Its it not in the realm of possibility that something on the catenary pole hit the windshield? (ladder, sign, bracket, etc.)  There is ample evidence the engine hit stuff after it derailed.  There is ample evidence the stuff it hit disfigured the front and sides of the engine. 

There is zero evidence that something was thrown at the windshield.  Has ANY official report, FBI or NTSB, said that the windhsield was hit by a rock BEFORE the train derailed?

Why is it so hard to accept that the damage to the engine happened after the engine derailed?

 

I am not claiming that there is proof that the windshield was hit by a thrown rock. I am claiming that there is evidence, which is what you asked me for in your previous comment. So I listed the evidence.

Now, you say there is zero evidence.  How can you possibly know that?  If there is zero evidence, it cannot be proven.  Since you cannot prove a negative, there is no way to know that there is zero evidence other than the evidence you look for but fail to find.  

As I said, I would be satisfied that a rock did not break the windshield if the break was analysed in a laboratory to the extent that the likely material causing the break was detected.  I would be stunned if that was done.  It was obvious that the NTSB was desperately running away from any thought of thrown rocks or especially bullets within hours of the derailment.

I agree with your point that anything could have poked the hole through the windshield.  Why is it so hard for you to accept that it could have been a thrown rock?

  • Member since
    December 2001
  • From: Northern New York
  • 24,924 posts
Posted by tree68 on Thursday, May 19, 2016 3:27 PM

dehusman
Why is it so hard to accept that the damage to the engine happened after the engine derailed?

What fun would that be?  Unless you want to fill untold pages wondering if it was a tie plate, or a track anchor, or....

I've got my own theory on the incident.  The engineer was out of his seat.  You see, his favorite sports team beat their arch rival (he heard the score during the layover) and he chose that moment to do a little "happy dance..."

You think he'd tell the investigators that?

 

LarryWhistling
Resident Microferroequinologist (at least at my house) 
Everyone goes home; Safety begins with you
My Opinion. Standard Disclaimers Apply. No Expiration Date
Come ride the rails with me!
There's one thing about humility - the moment you think you've got it, you've lost it...

  • Member since
    September 2003
  • From: Omaha, NE
  • 10,619 posts
Posted by dehusman on Thursday, May 19, 2016 3:19 PM

Norm48327
So, presumably, the windshield was inspected at the FBI labs and they said it was not a bullet.  That conclusion would most likely lead to a rock damaging the windshield.

Why does everybody assume that the only thing that can hit a windshield is a rock?  The engine obviously struck many things on its path after it left the rails (the entire engineer's side is scraped up, as is the nose.)  Lets say to scrape up the side it had to hit a catenary pole.  Its it not in the realm of possibility that something on the catenary pole hit the windshield? (ladder, sign, bracket, etc.)  There is ample evidence the engine hit stuff after it derailed.  There is ample evidence the stuff it hit disfigured the front and sides of the engine. 

There is zero evidence that something was thrown at the windshield.  Has ANY official report, FBI or NTSB, said that the windhsield was hit by a rock BEFORE the train derailed?

Why is it so hard to accept that the damage to the engine happened after the engine derailed?

Dave H. Painted side goes up. My website : wnbranch.com

  • Member since
    December 2007
  • From: Southeast Michigan
  • 2,983 posts
Posted by Norm48327 on Thursday, May 19, 2016 1:53 PM

Euclid
I would expect the NTSB to carefully remove the windshield, preserve the evidence, and send it to a laboratory for analysis of any materials left near the puncture in order to identify them. That would probably identify the cause of the hole in the windshield, and we would know then whether or not a thrown rock was the cause. Did the NTSB say they had done this as a means of supporting their claim that no rock was involved?

I believe the NTSB said that was done, and the FBI commented on it. So, presumably, the windshield was inspected at the FBI labs and they said it was not a bullet. That conclusion would most likely lead to a rock damaging the windshield. Now; thinking like a cop, if the FBI had evidence they thought could lead to prosecution of someone would they reveal it to the public? Not likely.

Norm


  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Thursday, May 19, 2016 1:37 PM

Prior to this final conclusion by the NTSB, they had two factors under consideration as the explanation for the engineer’s actions:

  1. Memory loss.

  2. Incapacitation.

Memory loss has been claimed by the engineer, and incapacitation could have been the cause of memory loss.  If the memory loss was a symptom of incapacitation, then incapacitation could have explained the engineer’s failure to slow down.

Now, the explanation has shifted to memory loss and distraction, but no incapacitation.  Without incapacitation as a cause of the accident, (and of memory loss), the accident needs a new cause.  That new cause is memory loss itself.  And the cause for that memory loss is now said to be distraction by the radio message.

Therefore, the new structure of cause is this:

 

  1. Radio transmission causes distraction.

  2. Distraction causes memory loss.

  3. Memory loss causes engineer to forget where he was in the territory.

  4. Engineer forgetting his location caused him to believe he should accelerate when he actually should have reduced speed.

  • Member since
    November 2005
  • 4,190 posts
Posted by wanswheel on Thursday, May 19, 2016 12:07 PM

Transcript of NTSB presentation by Stephen M. Jenner, Ph.D.

DR. JENNER: GOOD MORNING. THE FOCUS OF THE HUMAN PERFORMANCE INVESTIGATION WAS TO UNDERSTAND THE REASONS WHY A QUALIFIED, EXPERIENCED AND APPARENTLY ALERT ENGINEER FAR EXCEEDED A SAFE OPERATING SPEED AND FAILED TO SLOW HIS TRAIN AS HE APPROACHED THE CURVE AT FRANKFURT JUNCTION. THE AMTRAK ENGINEER TOLD INVESTIGATORS THAT HE COULD NOT REMEMBER THE EVENTS THAT OCCURRED MINUTES BEFORE THE ACCIDENT, INCLUDING HIS DECISION TO ACCELERATE THE TRAIN AS IT HEADED TOWARD FRANKFORD JUNCTION. AFTER ELIMINATING MANY OF THE HUMAN FACTORS THAT COULD HAVE AFFECTED HIS PERFORMANCE, THE INVESTIGATION FOCUSED ON THE FACTOR THAT MAY HAVE DIVERTED HIS ATTENTION AWAY FROM HIS OWN TRAIN OPERATION.

TO UNDERSTAND WHAT MAY HAVE HAPPENED, I NEED TO FIRST DISCUSS AN EMERGENCY SITUATION WITH ANOTHER TRAIN IN THE AREA JUST PRIOR TO THE ACCIDENT. A FEW MINUTES AFTER THE AMTRAK TRAIN DEPARTED ITS LAST STATION STOP AT 30TH STREET STATION, AN ENGINEER ON A SEPTA COMMUTER TRAIN THAT WAS APPROACHING NORTH PHILADELPHIA STATION BROADCAST ON A RADIO THAT A PERSON ALONG THE TRACKS HAD THROWN AN OBJECT AT HIS SEPTA TRAIN, SHATTERING THE WINDSHIELD, AND GETTING GLASS IN HIS FACE. AT THIS TIME, THE AMTRAK TRAIN WAS A COUPLE MILES BEHIND THE SEPTA TRAIN AND HEADED IN HIS DIRECTION ON AN ADJACENT TRACK.

FOR THE NEXT SIX MINUTES, ABOUT TWO DOZEN RADIO TRANSMISSIONS WERE MADE BETWEEN THE SEPTA TRAIN ENGINEER AND THE TRAIN DISPATCHER. THESE COMMUNICATIONS DISCUSS THE DETAILS OF WHAT HAD HAPPENED TO THE TRAIN, WHERE THE INCIDENT OCCURRED, THE CURRENT LOCATION OF THE SEPTA TRAIN, AND IF THE SEPTA ENGINEER REQUIRED MEDICAL ASSISTANCE. THE AMTRAK ENGINEER WAS CLOSELY MONITORING THIS RADIO CONVERSATION AND WAS ABLE TO ACURATELY RECALL THE CONTENT TO INVESTIGATORS. HE WAS CONCERNED THAT THERE MIGHT BE WORKERS ON THE TRACKS INSPECTING THE SEPTA TRAIN, WHICH WAS SOMETHING HE NEEDED TO LOOK OUT FOR. AND HE WAS VERY CONCERNED ABOUT THE SEPTA ENGINEER WHO HAD REQUESTED MEDICAL ASSISTANCE.

BEFORE THE AMTRAK TRAIN PASSED THE SEPTA TRAIN, THE AMTRAK ENGINEER MADE A RADIO BROADCAST INDICATING THAT HE WAS NEARING THE TRAIN ON TRACK 2. MOMENTS LATER, THE AMTRAK TRAIN PASSED THE DISABLED SEPTA TRAIN OPERATING AT OR NEAR TRACK SPEED. AFTER HE PASSED THE TRAIN THE AMTRAK ENGINEER CONTINUED TO PAY ATTENTION TO THE RADIO COMMUNICATIONS BETWEEN THE SEPTA ENGINEER AND THE DISPATCHER, WHICH LASTED FOR ANOTHER FEW MINUTES. STAFF BELIEVES THAT THE EMERGENCY SITUATION WITH THE SEPTA TRAIN IS SIGNIFICANT FOR THE FOLLOWING REASON: WITH HIS ATTENTION DIVERTED TO THE SEPTA TRAIN, THE AMTRAK ENGINEER MAY HAVE LOST SITUATIONAL AWARENESS. IN SHORT, SITUATIONAL AWARENESS IS HAVING AN ACCURATE UNDERSTANDING OF WHAT IS HAPPENING AROUND YOU AND WHAT IS LIKELY TO HAPPEN IN THE NEAR FUTURE.

I’D LIKE TO DISCUSS THE CONSEQUENCES OF HIS LOSING SITUATIONAL AWARENESS IN GREATER DETAIL, USING THIS MAP* OF THE ACCIDENT ROUTE. THIS MAP DEPICTS THE LAST EIGHT MILES OF THE ACCIDENT TRIP, STARTING AT THE 30TH STREET STATION IN PHILADELPHIA. THE STATION IS IDENTIFIED BY THE RED CIRCLE NEAR THE BOTTOM LEFT CORNER. THE AMTRAK TRAIN TRAVELED ABOUT 11 MINUTES AFTER HE DEPARTED THE STATION WHEN IT DERAILED AT FRANKFORT JUNCTION. THE DERAILMENT SITE IS IDENTIFIED BY THE RED X TOWARDS THE UPPER RIGHT CORNER. ABOUT A THIRD OF THE WAY BETWEEN THE 30TH STREET STATION AND FRANKFURT JUNCTION IS THE DISABLED SEPTA TRAIN. THE MAP ALSO SHOWS A SECTION OF TRACK BEYOND FRANKFORD JUNCTION, WHERE THE TRACK SPEED INCREASES FROM 60 TO 110 MILES PER HOUR.

I’LL ALSO BE REFERRING TO TWO RIGHT CURVES. THE FIRST IS A CURVE BEFORE THE DERAILMENT, IDENTIFIED BY THIS BLUE ARROW. THE SECOND RIGHT CURVE, WHICH IS LOCATED JUST AFTER THE DERAILMENT, IS IDENTIFIED BY THE GREEN ARROW. AS INDICATED BY THE ORANGE HIGHLIGHT ALONG THE ROUTE, THE SIX-MINUTE RADIO CONVERSATION BETWEEN THE SEPTA TRAIN ENGINEER AND THE DISPATCHER BEGAN AFTER THE AMTRAK ENGINEER DEPARTED 30TH STREET STATION AND ENDED AS THE AMTRAK TRAIN ENTERED THE CURVE BEFORE THE DERAILMENT, THE BLUE ARROW.

SHORTLY AFTER TRAVELING AROUND THE CURVE, THE ENGINEER, WHO WAS TRAVELING ABOUT 65 MILES PER HOUR, APPLIED FULL THROTTLE AND HELD IT AT ITS HIGHEST POSITION FOR ABOUT 40 SECONDS. THIS MANEUVER INCREASED THE TRAIN'S SPEED TO 106 MILES PER HOUR. GIVEN THAT THE MAXIMUM AUTHORIZED SPEED HERE WAS 80 MILES PER HOUR, THIS MANEUVER WAS NOT AN APPROPRIATE ACTION AT THIS LOCATION. HOWEVER, THIS MANEUVER WOULD HAVE BEEN APPROPRIATE AFTER THE CURVE JUST PAST THE DERAILMENT SITE, THE GREEN ARROW. FOLLOWING THAT CURVE, THE TRACK SPEED IS 110 MILES PER HOUR. HAD HE MADE IT THAT FAR, IT WOULD THEN HAVE BEEN APPROPRIATE TO ACCELERATE HIS TRAIN TO 106 MILES PER HOUR.

STAFF BELIEVES THAT BY THE TIME THE ENGINEER TRAVELED AROUND THE CURVE BEFORE THE DERAILMENT, THE BLUE ARROW, HE HAD LOST SITUATIONAL AWARENESS, AN AWARENESS OF WHERE HE CURRENTLY WAS, AND BELIEVED THAT HE WAS AT A LOCATION FARTHER DOWN THE TRACK, WHERE IT WAS APPROPRIATE TO ACCELERATE HIS TRAIN TO 106 MILES PER HOUR. AND GIVEN THAT IT WAS DARK OUTSIDE, THERE WERE FEWER VISIBLE CUES TO HELP HIM IDENTIFY HIS LOCATION. SO IN SUM, WITH HIS ATTENTION DIVERTED TO THE SEPTA TRAIN FOR SEVERAL MINUTES, THE ENGINEER MAY ULTIMATELY HAVE LOST TRACK OF WHERE HE WAS BEFORE HE ACCELERATED TO A HIGH RATE OF SPEED.

WHILE THE LOSS OF SITUATIONAL AWARENESS CAN AFFECT AN OPERATOR'S KNOWLEDGE OF WHERE HE CURRENTLY IS IN TIME AND SPACE, IT CAN ALSO AFFECT HIS ABILITY TO PERFORM UPCOMING TASKS. THE TERM PROSPECTIVE MEMORY DESCRIBES THE TYPE OF MEMORY PEOPLE USE FOR REMEMBERING TO PERFORM A PLANNED ACTION, OR AN INTENTION AT SOME POINT IN THE FUTURE. AN EXAMPLE IS REMEMBERING TO TAKE YOUR MEDICATION BEFORE GOING TO BED, OR REMEMBERING TO STOP OFF AT THE STORE ON YOUR WAY HOME TO PICK UP MILK.

BUT IT ALSO APPLIES TO OCCUPATIONAL SETTINGS, INCLUDING OPERATING ROOMS, OR COCKPIT OPERATIONS WHERE FLIGHT CREWS ARE REQUIRED TO REMEMBER A SERIES OF TASKS. TRAIN ENGINEERS ARE ALSO REQUIRED TO REMEMBER TO PERFORM A SERIES OF TASKS AS THEY OPERATE THROUGH A TERRITORY. THEY NEED TO REMEMBER ALL PERTINENT OPERATING RULES AS WELL AS PHYSICAL CHARACTERISTICS OF THE TERRITORY, INCLUDING THE LOCATION OF TRACK CURVES AND THEIR ASSOCIATED SPEED RESTRICTIONS. AND AS YOU SAW ON THE MAP, THERE WERE SEVERAL DIFFERENT SPEED RESTRICTIONS ALONG THIS ROUTE. AND BECAUSE TRAINS TAKE TIME TO SLOW DOWN, ENGINEERS NEED TO THINK AHEAD TO OPERATE THEIR TRAINS PROPERLY. HOWEVER, IF AN ENGINEER EXPERIENCES AN INTERRUPTION AND LOSES SITUATIONAL AWARENESS, HE MAY FORGET TO TAKE ACTION WHEN IT IS TIME TO DO SO.

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.

IN SUM, STAFF CONCLUDED THAT THE AMTRAK TRAIN ENGINEER ACCELERATED THE TRAIN TO 106 MILES PER HOUR WITHOUT SLOWING THE TRAIN FOR THE CURVE AT FANKFORD JUNCTION DUE TO HIS LOSS OF SITUATIONAL AWARENESS, LIKELY BECAUSE HIS ATTENTION WAS DIVERTED TO AN EMERGENCY SITUATION WITH THE SEPTA TRAIN. AS A REMINDER, POSITIVE TRAIN CONTROL WOULD HAVE PREVENTED THIS ACCIDENT. AS A RESULT, STAFF HAS PROPOSED SAFETY RECOMMENDATIONS IN THE AREAS OF EDUCATION, SIMULATOR TRAINING AND INTERCAB DEVICES, TO HELP PREVENT THESE TYPES OF ACCIDENTS FROM HAPPENING AGAIN.

* Map is on page 15 http://www.ntsb.gov/news/events/Documents/2016_Amtrak_BMG_Presentations.pdf

 

  • Member since
    June 2002
  • 20,048 posts
Posted by daveklepper on Thursday, May 19, 2016 9:44 AM

And I still maintain that there is still no proof given for the FBI ascwertation that it was not a terrorist attack.   I am not maintaining that that in itsel is proof that it was a terrorist attick, simply that that case is really still open.

  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Thursday, May 19, 2016 9:12 AM

dehusman
 
Euclid
I think it is far more likely that the engineer was distracted by a rock hitting his windshield. How do we know that didn’t happen?

 

What evidence do you have of a rock hitting the windshield?

The NTSB didn't mention any evidence of a rock hitting the windshield.

The engineer never reported a rock hitting the windshield.

There are dozens of damaged locations on the engine, things torn off, things scraped off, impact damage all over the front, bottom and side of the engine.  What makes you so sure that the damage to the windshield is not part of all the other damage done in the derailment?

In order for the rock thing to work, the train would have had to have been rocked before the train accelerated, the engineer in a state of impairment would have had to have made a normal acceleration.

If there is no evidence of that happening why is it "far more likely" than the NTSB's version of events.  Based on reading accident reports and investigating acidents over the last 37 years, the NTSB report sounds pretty likely to me.

 

Dave,

Certainly, there is some circumstantial evidence of a rock hitting the windshield as follows:

  1. There was a hole in the windshield that could have been caused by striking a thrown rock.

  2. There was a rock throwing incident nearby at that time.

  3. It is unlikely that the derailed engine could have dislodged a rock in a way that that the rock would not be propelled forward at approximately the same speed of the engine, and thus not presented an obstacle with enough resistance to puncture the windshield, had the windshield managed to catch up with the rock.

  4. While it is true that the engine was damaged in several places, all of that was caused by the engine striking stationary objects.  What stationary object could have plausibly punctured a small hole in the windshield?  It is possible that the locomotive could have hit a structure, accelerating that structure so quickly that it left parts behind as they tore off from the acceleration; and then those parts left behind were relatively stationary when the windshield hit them at full speed.  That could have caused a hole in the windshield.  I cannot say whether that is likely or probable.

Remember, the NTSB has now taken us from the root cause of impairment to that of distraction.  I am suggesting that a thrown rock strike might have distracted the engineer, not impaired him.  There is no reason that the engineer could not have accelerated normally if he were distracted instead of impaired.  That is exactly now what the NTSB has concluded.  He accelerated with normal cognition, but the distraction introduced just prior caused him to mistakenly believe he was in the proper location for the acceleration.

When I say “far more likely,” I mean far more likely that the engineer’s level of distraction was caused by a rock busting his windshield than by just hearing about somebody else’s windshield getting busted.  Which would be more distracting? 

Given all of this, I would expect the NTSB to carefully remove the windshield, preserve the evidence, and send it to a laboratory for analysis of any materials left near the puncture in order to identify them.  That would probably identify the cause of the hole in the windshield, and we would know then whether or not a thrown rock was the cause.  Did the NTSB say they had done this as a means of supporting their claim that no rock was involved? 

I agree that a thrown rock would have been reported or recalled by the engineer. However, we have been told all along that the engineer has memory loss and does not remember anything of the timeframe where a thrown rock could have occurred.   

  • Member since
    January 2014
  • 8,175 posts
Posted by Euclid on Thursday, May 19, 2016 8:21 AM

schlimm

Euclid:  The engineer's memory loss is most likely a sequella of the accident, not the cause.  "Loss of situational awareness" is just lingo for his confusion.

 

Schlimm,

I agree that memory loss likely played no role in the derailment.  In my opinion, memory loss likely was caused by the engineer’s defense mechanism pushing back and attempting to deny the realization of the terrible mistake he had made.  Especially for a person as conscientious of doing good work in a job he loved, that mistake must have played on him with the weight of the world. 

  

  • Member since
    July 2006
  • 9,610 posts
Posted by schlimm on Thursday, May 19, 2016 8:06 AM

dehusman

 

 
Euclid
I think it is far more likely that the engineer was distracted by a rock hitting his windshield. How do we know that didn’t happen?

 

What evidence do you have of a rock hitting the windshield?

The NTSB didn't mention any evidence of a rock hitting the windshield.

The engineer never reported a rock hitting the windshield.

There are dozens of damaged locations on the engine, things torn off, things scraped off, impact damage all over the front, bottom and side of the engine.  What makes you so sure that the damage to the windshield is not part of all the other damage done in the derailment?

In order for the rock thing to work, the train would have had to have been rocked before the train accelerated, the engineer in a state of impairment would have had to have made a normal acceleration.

If there is no evidence of that happening why is it "far more likely" than the NTSB's version of events.  Based on reading accident reports and investigating acidents over the last 37 years, the NTSB report sounds pretty likely to me.

 

Of course.  Well said, but it won't stop Euclid's journey to Obtuseanium [credits to another member].

C&NW, CA&E, MILW, CGW and IC fan

  • Member since
    September 2003
  • From: Omaha, NE
  • 10,619 posts
Posted by dehusman on Thursday, May 19, 2016 8:03 AM

Euclid
I think it is far more likely that the engineer was distracted by a rock hitting his windshield. How do we know that didn’t happen?

What evidence do you have of a rock hitting the windshield?

The NTSB didn't mention any evidence of a rock hitting the windshield.

The engineer never reported a rock hitting the windshield.

There are dozens of damaged locations on the engine, things torn off, things scraped off, impact damage all over the front, bottom and side of the engine.  What makes you so sure that the damage to the windshield is not part of all the other damage done in the derailment?

In order for the rock thing to work, the train would have had to have been rocked before the train accelerated, the engineer in a state of impairment would have had to have made a normal acceleration.

If there is no evidence of that happening why is it "far more likely" than the NTSB's version of events.  Based on reading accident reports and investigating acidents over the last 37 years, the NTSB report sounds pretty likely to me.

Dave H. Painted side goes up. My website : wnbranch.com

  • Member since
    July 2006
  • 9,610 posts
Posted by schlimm on Wednesday, May 18, 2016 10:45 PM

Euclid:  The engineer's memory loss is most likely a sequella of the accident, not the cause.  "Loss of situational awareness" is just lingo for his confusion.

C&NW, CA&E, MILW, CGW and IC fan

Join our Community!

Our community is FREE to join. To participate you must either login or register for an account.

Search the Community

Newsletter Sign-Up

By signing up you may also receive occasional reader surveys and special offers from Trains magazine.Please view our privacy policy