Amtrak Wreck in Philadelphia

[Wizlish]

wanswheel

Excerpt from NTSB press release, July 8

http://www.ntsb.gov/news/press-releases/Pages/PR20150708.aspx

In a letter to Amtrak today, the National Transportation Safety Board said that it should install crash- and fire-protected inward- and outward-facing audio and image recorders in the operating cabs of all of its trains, and review the recordings to ensure that crew actions are in accordance with procedures.

In other words, precisely the worst outcome for Amtrak engine crews.

Will be interesting to see how this spreads to freight railroads.  I suspect the camel's nose will be for railroads that operate over Amtrak trackage.  (An excuse or pretense, of course, but there's the modern version of 'think of the children!' -- think of passenger safety!...)

But then again, remember our boys on the Malabar front ... just think what THEY have to put up with...

[wanswheel]

Excerpt from NTSB press release, July 8

http://www.ntsb.gov/news/press-releases/Pages/PR20150708.aspx

In a letter to Amtrak today, the National Transportation Safety Board said that it should install crash- and fire-protected inward- and outward-facing audio and image recorders in the operating cabs of all of its trains, and review the recordings to ensure that crew actions are in accordance with procedures.

[BOB WITHORN]

I lost 40 pounds and my wife said almost all of the sleep apnea dissapeared. Now that I've succeeded in regaining most of those pounds, it's back.

[Wizlish]

gardendance

I'm probably mixing up trains.com posts with the deluge of medical professionals who claim that eating less and exercising more is a magical cure for all of my ailments.

Also, be careful to distinguish those who claim 'eating too much and exercising too little contributed to your ailments' from those claiming that eating less and exercising more will help relieve them'.

As an interesting peripheral point -- there was some proof that proper dietary change and exercise could reverse the effects of heart disease, at least short of patent infarction damage.  I am not sure I fully believe that, but if some part of that is in reducing the tendency for 'immune' response to cause clotting on plaque deposits, and if plaque or arterial-wall damage turns out to resorb over time, there may be something in it. 

I do think there will be evidence that OSA symptoms will tend to decrease if obesity is relieved (by non-stressful means!)  Some of that improvement may be due to a concomitant increase in basal metabolism, or other factors associated with physical amelioration of obesity.  I would want to avoid any sense of post hoc, ergo propter hoc, though.

[gardendance]

Wizlish

 

 

gardendance

There are so many comments implying that losing weight will cure my sleep apnea

 

 

I believe there is only one comment indicating that actively 'losing weight' may reduce sleep apnea, the last one.

 

I'm probably mixing up trains.com posts with the deluge of medical professionals who claim that eating less and exercising more is a magical cure for all of my ailments.

Does anybody remember Dr McCoy's comment in The Omega Glory " I can do more for you if you just eat right and exercise regularly"?

[daveklepper]

Except that there remains the possibility that his lack of awareness and reduced consiousness was caused by a projectile hitting the windshield or even hitting him.  Not proven, but remaining a possibility.   He would still have some responsibility, but the main responsibility would be on whoever launched whatever the projectile was.

[schlimm]

tree68

 

 

dehusman

..... or instead of all these disorders and conditions and pop psychology he could have been wide awake and just lost track of where he was.  Lots of cases where TWO people in the cab, in broad daylight, tell the dispatcher they are at one location and are really someplace else.

 

 

Simply attempts to blame someone/something other than the engineer for what happened.

 

 

Whether or not the engineer had sleep apnea, a seizure disorder or was simply inattentive for other reasons, the responsibility is still his. Finding causation is not the same as blame.  Understanding the root causes allows for a scientific approach that may lead to prevention.  Your approach seems to be one of "s*** happens."

 

"pop psychology"?    Hardly.   The comments on sleep apnea and seizure disorders are those of a trained professional with years of experience.

[Wizlish]

Euclid

I do not believe that this discussion of sleep disorders includes any conclusion or assertion that they were the cause of this wreck. They exist only as a possibility, and nobody has said otherwise.

With justice to Dave et al., I can see how he might reach that conclusion; much in the preceding few posts were concerned with the MN Spuyten Duyvil accident, where sleep apnea was ultimately considered a primary causative factor -- rightly or wrongly.  There has been more than one comment in this thread that some 'excuse' will be found in the final report, and with the Rockefeller precedent, I'd be surprised if 'fatigue' weren't brought up in some form for some purpose.

On the other hand, I think there is a difference between looking at ways this accident could have happened and determining a basis to prejudge the engineer for incompetence or worse.  The latter, justified as it may turn out to be, should be reserved for after the NTSB finishes their report.

[Euclid]

tree68

 

dehusman

..... or instead of all these disorders and conditions and pop psychology he could have been wide awake and just lost track of where he was.  Lots of cases where TWO people in the cab, in broad daylight, tell the dispatcher they are at one location and are really someplace else.

 

 

Simply attempts to blame someone/something other than the engineer for what happened.

 

I do not believe that this discussion of sleep disorders includes any conclusion or assertion that they were the cause of this wreck.  They exist only as a possibility, and nobody has said otherwise.    

[tree68]

dehusman

..... or instead of all these disorders and conditions and pop psychology he could have been wide awake and just lost track of where he was.  Lots of cases where TWO people in the cab, in broad daylight, tell the dispatcher they are at one location and are really someplace else.

Simply attempts to blame someone/something other than the engineer for what happened.

[dehusman]

..... or instead of all these disorders and conditions and pop psychology he could have been wide awake and just lost track of where he was.  Lots of cases where TWO people in the cab, in broad daylight, tell the dispatcher they are at one location and are really someplace else.

[daveklepper]

Explains the emergency brake application as his body felt the lerch entering the curve.

[schlimm]

Wizlish

I had been hypothesizing a state of consciousness akin to what I thought was called 'twilight sleep', in which conscious attention might lapse while even quite complex learned activity continued -- much as people can drive without having a memory of how they got somewhere.  [Schlimm, what's the right technical term for this?]

Specifically a form of automaticity.  These are states of consciousness in which there is hypnotic dissociation.

Wizlish

armodafinil

Nuvgil (armodafinail) is considered a dopamine receptor agonist, most similar in action to Provigil.  it is also somewhat similar in pharmacodynamics to amphetamines and methylphenidate (Ritalin).

[Euclid]

Wizlish

 

Euclid

But on the face of it, the net result of SWD is that it amounts to deadly loophole in the presumption of safety. In the context of shiftwork, the risk of SWD turns every safety sensitive task into a game of Russian roulette for everyone involved.

 

 

I don't know if it needs to be quite so dramatic. 

 

Well, did say, “In my opinion, it is possible that the risk of SWD has been exaggerated.”

However if it is not exaggerated, it is exactly what I said it is.  I wanted to state it dramatically because it is a very dramatic proposition.  I don’t think that the average person is aware of that. 

Most people are under the impression that the whole problem revolves around night shift workers being kept awake by a world engaged in noisy daytime activities.  They believe that if you are thus sleep deprived, you will feel tired at night while working, and may nod off if doing something that is relatively sedentary.  That model of the sleep problem from working nights has been around for as long as people have worked nights.  Current SWD is entirely different, and only a few decades old.        

[tree68]

Wizlish

I had been hypothesizing a state of consciousness akin to what I thought was called 'twilight sleep', in which conscious attention might lapse while even quite complex learned activity continued...

There was an anecdote in Trains a while back involving an old-head engineer who amazed his (trainee?) fireman by blowing for all crossings, correctly, while apparently sound asleep.

[Wizlish]

Euclid

But on the face of it, the net result of SWD is that it amounts to deadly loophole in the presumption of safety. In the context of shiftwork, the risk of SWD turns every safety sensitive task into a game of Russian roulette for everyone involved.

I don't know if it needs to be quite so dramatic. 

On the other hand, I am beginning to see something emerging from the complex of SWD, OSA, perhaps even seizure induction, that poses an interesting opportunity for research and perhaps action.

I had been hypothesizing a state of consciousness akin to what I thought was called 'twilight sleep', in which conscious attention might lapse while even quite complex learned activity continued -- much as people can drive without having a memory of how they got somewhere.  [Schlimm, what's the right technical term for this?] I then wondered if stresses like those in 'wrong direction' SWD, or aggravated sources of fatigue like frustration over cab-signal malfunction, might contribute to something like narcolepsy.  And -- perhaps interestingly -- I come across this, in a drug description:

NUVIGIL^® (armodafinil) Tablets [C-IV] is a prescription medicine used to improve wakefulness in adults who experience excessive sleepiness due to one of the following diagnosed sleep disorders: obstructive sleep apnea (OSA), shift work disorder (SWD), or narcolepsy.

schlimm is likely to know the method by which this drug (and perhaps others like it) act, and perhaps whether it would be legal or advisable for, say, railroaders with 'risk factors for drowsiness' to try it or take it, etc.

[wanswheel]

Off-topic and probably old news around here, a little game to test reaction time.

https://www.railroadersleep.org/railroad-sleep/read-your-signals/game-reaction-time.aspx

[Euclid]

In my opinion, it is possible that the risk of SWD has been exaggerated.

But on the face of it, the net result of SWD is that it amounts to deadly loophole in the presumption of safety.  In the context of shiftwork, the risk of SWD turns every safety sensitive task into a game of Russian roulette for everyone involved.  It is like a traffic light that sometimes shines green in both directions. 

This is the incredible gravity of SWD as it is currently defined.  Yet, as far as I know, there is nothing officially in place to remedy the danger posed by SWD to safety sensitive jobs.  But if the risk is real, then every locomotive should be parked until the SWD problem has been resolved.

For that not to be happening, is an indication to me that the industry either believes that the SWD problem has been exaggerated or is in denial about it.  Certainly any sane business that accepts the premise of SWD would not have people running trains unless they were known to be free of SWD.    

[tree68]

While shiftwork can (and does) cause sleep issues, I wonder if that's the appropriate "diagnosis" in this case, or if it's the irregular sleep instead.  While the two are similar, I would submit that they are not the same.  We've discussed the irregular sleep thing here before, especially as it applies to road crews which may be on what amounts to a 22 hour clock (or less).

It's been known for some time that if you're going to rotate shifts, the proper direction is "forward," ie, days to eves, eves to mids, etc.  Going "backwards" is a recipe for disaster, as the transition (your body getting as used to the shift as it's going to) is that much longer.  I'm sure research has been done on how long the transition is - I don't know myself.  

I once interviewed for a job that was on a one week rotation - talk about a recipe for never catching up.

On the other hand, I had an uncle who worked mids all the time - and always looked beat.

When I was on shift work, eves weren't bad - you still got home and slept at night.  Mids were tough, especially as a single father.  You try to sleep during the day, but having the kids around, and having to deal with life's obligations certainly cut into that.

But anyone who has done shiftwork knows that.

[jeffhergert]

schlimm

According to the Mayo Clinic and others, weight loss and other lifestyle changes (not sleeping on back, exercise) are major treatment modalities along with possible medicatios, CPAP and surgery depending on severity.  Obesity is a prime factor for OSA and type II diabetes and a host of cardiovascular problems.

The reason OSA was brought up here was because it was a factor in the MetroNorth accident and it isn't always known to the sufferer.  But Bastian does not appear to be obese and I think if there is a medical cause for his lapse in attention, it might be a seizure disorder as I have suggested since early on.

 

I was reading on another forum about an engineer who fainted on the job.  It was determined the reason was dehydration and poor diet.  (His doctor has cleared him to return to work.  The railroad, so far, has not.)

I put this out there not because I think this is the case with this incident.  Rather, it seems there are more reasons why a person could "black out." 

Eventually it seems, humans may be deemed to fragile to work in any safety sensitive positon.  Let machines and computers do the work because even the healthiest appearing person could have something that could incapacitate them at any time .  

Maybe that's what they want. 

Jeff 

[Euclid]

I had started two threads on sleep disorders about 2-3 years ago.  The first one was locked due to acrimony.  Both probably are accessible somehow.  Generally, this is what I learned in the course of the two threads:

Sleep disorder known as Shift Work Disorder (SWD) can be caused by working nightshift.  Traditionally, I believe it has been associated with working rotating shift, but as I understand, that is not the essential cause, except to the extent that it includes a nightshift.  That point does seem a bit fuzzy, however.  In any case, it is not simply a matter of failing to get enough sleep during sleep time. 

Therefore anybody working night shift or rotating shift is at risk for acquiring SWD.  If a person is afflicted with SWD, they are subject to the possibility of spontaneously falling asleep at any time without necessarily feeling drowsy or tired.  So this is a fatal flaw in the presumption that human attention can be maintained in a safety-critical job activity such as running a locomotive.

This means that anyone engaged in any such safety-critical job that includes nightshift work must be evaluated to see if they have SWD.  If they do, they must be taken out of service and successfully treated for SWD.

This goes way beyond the traditional, common sense belief that the only risk is failing to get sufficient rest during time off.  It is not about just staying up late and being consciously tired during the next work shift.

In those threads, I saw the conclusion that employees working night shift in safety sensitive activity must be evaluated for SWD.  If they are found to have it, they must be treated and cured; or they must be technologically monitored while working in order to assure that they are not sleeping.  The technological monitoring has not yet been perfected for practice, so that leaves the only option as testing for SWD, and successfully treating it.

It is my impression that the unions feel this is overly intrusive, and jeopardizes an employee’s job.  So the evaluation for SWD is viewed with the same wariness as inward facing cameras.  I do not know if SWD evaluation is 100% reliable.  Nobody wants to risk losing their job due to a faulty conclusion that they have SWD.

So, this of course does tie into the topic of the Amtrak derailment because Bostian would be at risk for SWD, and the symptoms of SWD include spontaneously falling asleep, which could have played a role in the cause the derailment.       

[schlimm]

According to the Mayo Clinic and others, weight loss and other lifestyle changes (not sleeping on back, exercise) are major treatment modalities along with possible medicatios, CPAP and surgery depending on severity.  Obesity is a prime factor for OSA and type II diabetes and a host of cardiovascular problems.

The reason OSA was brought up here was because it was a factor in the MetroNorth accident and it isn't always known to the sufferer.  But Bastian does not appear to be obese and I think if there is a medical cause for his lapse in attention, it might be a seizure disorder as I have suggested since early on.

[Wizlish]

gardendance

There are so many comments implying that losing weight will cure my sleep apnea

I believe there is only one comment indicating that actively 'losing weight' may reduce sleep apnea, the last one.  The others all address obesity as an aggravating factor, something that would be used in determining priorities for fatigue management plans.  I do not know, and evidently neither do you, whether a developed case of sleep apnea can be "cured" by relieving the obesity -- any more than, for example, congestive heart failure would be.  (I'd be interested in finding that out, and if you're obese and have sleep apnea, I think you should be, but there's what Dorothy Parker said about garden dancing, in a sense...)

[gardendance]

There are so many comments implying that losing weight will cure my sleep apnea. Keep this up and I'll stop reading this thread, and I'm sure none of you want that to happen.

Seriously though, I don't see how sleep apnea and fatigue are the subject at hand for this thread. What do they have to do with Amtrak 188's wreck? I thought the authorities had already ruled out, or seriously downplayed fatigue, and what evidence do we have that says Bostian, not apparently overweight, has apnea?

While we're at it, haven't the authorities also ruled out locomotive failure, or again at least seriously downplayed it?

[schlimm]

Wizlish

Getting back to the topic discussion (or a logical part of it, at least)

 

 

schlimm

I would hope a structure for screening could be established quickly. Not all engineers would need a sleep study, so expenses could be reduced. Only those with the primary risk factor of obesity are likely candidates.

 

 

I notice that today marks the introduction of the first FDA-approved implanted OSA treatment system (Inspire Medical Systems). 

There are or ought to be particular advantage of this device for many T&E people over treatment modalities like conventional CPAP.  The device can be used conveniently at any 'away' location -- even those without available electrical power or amenities.

 

That is good.  However, lifestyle changes are also needed, primarily weight loss and exercise.

[Wizlish]

Getting back to the topic discussion (or a logical part of it, at least)

schlimm

I would hope a structure for screening could be established quickly. Not all engineers would need a sleep study, so expenses could be reduced. Only those with the primary risk factor of obesity are likely candidates.

I notice that today marks the introduction of the first FDA-approved implanted OSA treatment system (Inspire Medical Systems). 

There are or ought to be particular advantage of this device for many T&E people over treatment modalities like conventional CPAP.  The device can be used conveniently at any 'away' location -- even those without available electrical power or amenities.

 

[tree68]

Randy Stahl

 

 

tree68

 

Randy Stahl

Although I get nasty foot cramps pulling a stiff bell valve out.

 

 

One of our ALCOs has a toggle switch for the bell....  It's electrically activated.

 

 

 

 

They think of everything.

R 

Kind of a pain sometimes, though, as it's nowhere near where the bell valve usually is found...

[Randy Stahl]

tree68

 

Randy Stahl

Although I get nasty foot cramps pulling a stiff bell valve out.

 

 

One of our ALCOs has a toggle switch for the bell....  It's electrically activated.

 

They think of everything.

R

[tree68]

Randy Stahl

Although I get nasty foot cramps pulling a stiff bell valve out.

One of our ALCOs has a toggle switch for the bell....  It's electrically activated.

[Wizlish]

Deggesty

Randy

You can run older locomotives with your toes.. Although I get nasty foot cramps pulling a stiff bell valve out.

Prehensile toes?

Not prehensile enough!