Amtrak Train Strikes Backhoe South of Philadelphia

[Euclid]

BaltACD

 

Euclid

Even without knowing what caused this backhoe crash, I conclude that the primary thing that was missing from the safety system was the ability of the track crew to know that they had no protection.  Obviously they had no protection and did not know that. If they had known that, the collision probably would not have happened.

 

 

It seems that everyone but the backhoe operator knew there was no protection in place.  Did he arrive late for the day and miss the job briefing?  Did he have to make a nature call during the job briefing?  Did he not pay any attention during the job briefing.  Why did the backhoe operator do what he did?  That is the unanswered question.

 

I don't know who was there besides the backhoe operator and the supervisor who tried to save him.  Maybe they were the only ones.  But if so, why would you assume that the supervisor knew there was no protection in place?  Why would anybody in that circumstance knowingly foul a track without protection?  Why do you say that it seems that everyone but the backhoe operator knew there was no protection in place?

[Electroliner 1935]

As Shakespere would say, "Ay, there's the rub". Why did the backhoe operator "ASSUME" he had protection. We infer that he knew he needed protection and that he thought he had protection. How did he know he needed protection? From training? And if he did know he needed it, why would he then work where he was without it. So we then infer that he thought he had it. Why did he think he had it? Did an EIC tell him he had it? Or did he not have proper training? I think we will have to wait for the TSB to tell us. I don't think anyone on the forum knows. I sure as hell don't. And I'l bet all other crews  are crossing their t's and doting their i's on their protection training. 

[Euclid]

Here is a little news about the shunts.  Somebody should tell Mr. Dodd that shunt straps are just a red herring and not a root cause.

http://www.pressreader.com/

From the link:

“Mr. Dodd [head of track workers union] said he believes trainers aren’t telling the track employees they can insist on using shunt straps, devices attached to rails to prevent a train from entering a work zone.

According to four people briefed on the accident, the lapses included the lack of shunt straps.  The FRA asked Amtrak to ensure roadway workers know where and how to acquire the equipment.”

Amtrak requires workers to use shunts in many situations, the [Amtrak] spokeswoman said.  She declined to comment on whether Amtrak workers used a shunt before the Chester crash.”

 

[tree68]

Euclid

Here is a little news about the shunts.  Somebody should tell Mr. Dodd that shunt straps are just a red herring and not a root cause.

I'm sure he knows that already.  In fact, no where in the quote does he say otherwise.  He's just talking about shunts - not the cause of the incident. 

Recall that a shunt can't be used without the permission of the dispatcher.   A worker can't just decide to throw it on at will.

If the work zone had been established IAW established procedures, then the shunt could  have been used.  

The shunt is a secondary means of protection.  Maybe Amtrak MOW isn't using the shunt as they should be, but I would opine that it is in part because they've found that following established procedures for securing protection has been sufficient in the past.

Edit - Besides, he represents labor.  It's his job to spin this in a way that makes management look bad, and labor to look good.

That's not a knock on unions - but it's how it works.

 

[Euclid]

 

tree68

 

Euclid

Here is a little news about the shunts.  Somebody should tell Mr. Dodd that shunt straps are just a red herring and not a root cause.

 

 

I'm sure he knows that already.  In fact, no where in the quote does he say otherwise.  He's just talking about shunts - not the cause of the incident. 

Recall that a shunt can't be used without the permission of the dispatcher.   A worker can't just decide to throw it on at will.

If the work zone had been established IAW established procedures, then the shunt could  have been used.  

The shunt is a secondary means of protection.  Maybe Amtrak MOW isn't using the shunt as they should be, but I would opine that it is in part because they've found that following established procedures for securing protection has been sufficient in the past.

Edit - Besides, he represents labor.  It's his job to spin this in a way that makes management look bad, and labor to look good.

That's not a knock on unions - but it's how it works.

Mr. Dodd was not as dismissive of the relevance of shunts as you suggest.  And while you have tied that implication to my suggestion that he be told that shunts are not the central issue, I was being facetious. 

Of course Mr. Dodd was referring to shunts as they relate to the cause of this accident, and also to the risk posed by Amtrak not training in the use of shunts or making shunts available to employees.  His whole point in mentioning shunts was in relation to this accident and the fact that they could have prevented it.

I agree that the shunt is a secondary means of protection; however, in this case, it would have saved two lives.  So being a secondary means does not diminish its relevance, as you imply.  If anything it increases the relevance because the secondary protection is the last chance to prevent an accident.      

You and others have stipulated that the shunt cannot be used without permission from the dispatcher.  Why is that relevant?  It does not undermine the case for using a shunt.

If a track worker has permission, or could ask for and receive permission, it is still his own decision as to whether or not to go ahead and use the shunt.  If the track workers had asked to use a shunt, and the dispatcher said no, then the dispatcher would have made the decision to not use a shunt.  But either way, the relevance of the shunt is not at all diminished by the fact that the dispatcher must approve the use of the shunt.     

 

[wanswheel]

Excerpt from New Haven Register, June 21, 2013

http://www.nhregister.com/article/NH/20130621/NEWS/306219825

Metro-North will implement a pilot program of using a shunting system to increase the safety of workers on the tracks, according to the railroad.

The pilot program will go into effect within four weeks, according to a letter sent today from Metro-North President Howard Permut to U.S. Sen. Richard Blumenthal, D-Conn…

"Shunting devices in isolation are not redundant signal protection nor are they fully effective in preventing a train from traveling into an area that has been turned over to right-of-way maintenance employees," Permut wrote.

"The placement of these devices, like any kind of safety technology, is critical and they cannot be installed without proper planning and training. These devices must be close enough to the work crew to restrict the engineer's speed but far enough away to ensure that, if the device fails, the engineer has sufficient time to stop the train safely. It is best to combine a shunting device with a physical barricade, providing a supplement to the signal system and a visual 'stop sign' as the train approaches."

[tree68]

Euclid

You and others have stipulated that the shunt cannot be used without permission from the dispatcher.  Why is that relevant?  It does not undermine the case for using a shunt.

You're absolutely correct - it does not undermine the case for using a shunt.

What it absolutely underlines, however, is the necessity of contacting the dispatcher.  In this case, had someone contacted the dispatcher to request use of the shunt, they would have been given working limits along with permission to use the shunt and the train would not have been on the tracks.

If the track workers had asked to use a shunt, and the dispatcher said no, then the dispatcher would have made the decision to not use a shunt.

Also absolutely correct - but it would then be known that either a> a work zone had been established and work could proceed, or b> a work zone had not been established and the MOW workers did not have permission to occupy that track.

Focusing on the shunt merely distracts from the root problem here - a failure to communicate.

[Euclid]

tree68

 

Euclid

You and others have stipulated that the shunt cannot be used without permission from the dispatcher.  Why is that relevant?  It does not undermine the case for using a shunt.

 

 

You're absolutely correct - it does not undermine the case for using a shunt.

What it absolutely underlines, however, is the necessity of contacting the dispatcher.  In this case, had someone contacted the dispatcher to request use of the shunt, they would have been given working limits along with permission to use the shunt and the train would not have been on the tracks.

 

If the track workers had asked to use a shunt, and the dispatcher said no, then the dispatcher would have made the decision to not use a shunt.

 

 

Also absolutely correct - but it would then be known that either a> a work zone had been established and work could proceed, or b> a work zone had not been established and the MOW workers did not have permission to occupy that track.

Focusing on the shunt merely distracts from the root problem here - a failure to communicate.

 

If there was a failure to communicate, I agree that that was the primary problem.  However, asking for a shunt would have revealed that primary problem and saved the day, as you point out.  Asking for the shunt would have revealed that no foul protection was in place.  It would have revealed the failure to communicate, so the failure could have been remedied before running its course and resulting in the crash. 

It would be interesting to know what Amtrak's rules actually are regarding the use of wire shunts in a case like this.  From what has been described, it sounds like it is optional and perhaps conflicted by being somewhat encouraged and somewhat discouraged; both in the name of safety.    

[tree68]

Euclid

If there was a failure to communicate, I agree that that was the primary problem.

So far, that seems to be the consensus.

Anything that would have reminded the EIC to contact the DS (or vice versa) would have remedied the situation.  That could include any employee in the chain of command, including the backhoe operator and his immediate supervisor (if that wasn't the EIC).

At this point, we don't know if the backhoe operator assumed he could set on, or was told he could set on, and if so, by whom.  All we know is that he did.  Or did he?  Was the backhoe already on?  Was it left on the tracks by the previous crew?  We simply don't know at this point.

I would think that if the previous EIC cancelled his work zone, removal of a shunt (if it had been put on) would have been part of that cancellation.

While the shunt is an important tool, at this point it's simply a distractor from those who are truly responsible - and we have to wait until NTSB decides who that is so they can fill us in.  

Now, if the shunt issue is a symptom of a larger issue with the safety culture, so be it.  But it would appear that it would simply be a symptom.  The issues appear to be much larger.

I would opine that the union leader's raising of the shunt issue may be an attempt to deflect responsibility from the workers (who actually use the procedures) to management.  

 

[Euclid]

 

tree68

I would opine that the union leader's raising of the shunt issue may be an attempt to deflect responsibility from the workers (who actually use the procedures) to management.  

Yes I can see that being the case.  In reading the other parts of the article that I quoted above, there does indeed seem to be quite the adversarial relationship between Mr. Dodd and his union versus Amtrak. 

 

[n012944]

Euclid

 

 

 

 

 

 

If there was a failure to communicate, I agree that that was the primary problem.  However, asking for a shunt would have revealed that primary problem and saved the day, as you point out.  Asking for the shunt would have revealed that no foul protection was in place.  It would have revealed the failure to communicate, so the failure could have been remedied before running its course and resulting in the crash.  

There obviously was not a proper job briefing held between the 1st shift dispatcher, and the 1st shift EIC.  The whole shunt thing is a moot point.  The 1st shift EIC could have called the dispatcher asking if it was ok to wear purple bandanas while fouling the track with the backhoe, at least the dispatcher would have then known their intentions was to foul, and if proper blocking had been applied for them to do so.

 

Proper job briefings is what needs to be stressed, not if and when a shunt being dropped is talked about.

[Electroliner 1935]

Does anyone know whether the supervisor who died was the EIC?

[Sunnyland]

When I first heard about it, a friend and I thought sabotage by someone wanting to cause a wreck and leaving a backhoe on tracks. Then it came out that it was 2 Amtrak workers killed.  Mistakes were made big time by someone in charge I discussed it with 2 friends, one was signal maintainer and super for A&S and other was engineer for BNSF. They both said trains should not be on same track where work being done and blamed it on dispatch for incorrect orders.   This is all Amtrak owned tracks too, so not like miscommunication with a host railroad.   I feel very sorry for the workers who were killed and the engineer who hit them. It's not like it was some stupid fool who ran around the gates and was hit by train.  My BNSF engineer has killed people who did that, he said he can't let it bother him, he was where he was supposed to be and they were not.   But this is a whole different scenario and someone up the chain was to blame for not setting up proper clearance for train and workers.   I often hear UP trains tooting for MOW workers in the summer as they run through Maplewood, MO, same tracks used by Amtrak too. They are supposed to constantly toot as they are passing crews who stand aside with their equipment but it's double track there too,so trains can be switched over a short distance to pass the MOW crews.

 

[Electroliner 1935]

Sunnyland

I often hear UP trains tooting for MOW workers in the summer

When I listen to the scanner, and the BNSF dispatcher is giving order for trains to operate through a work zone, they always state, "whistle freely ond often" as part of their order. They also note who the EIC is and to contact them for permission to occupy the work zone.

[wanswheel]

Pete Adamovich rest in peace

http://www.goiam.org/index.php/imail/latest/15867-tcu-iam-mourns-member-killed-in-amtrak-crash

[BaltACD]

Sunnyland

But this is a whole different scenario and someone up the chain was to blame for not setting up proper clearance for train and workers.

On my carrier, MofW personnel that request track time, either with a 'hi-rail' type request or a work zone occupancy, MUST posess a current day's Train Bulletin for the territory involved.  The Train Bulletin contains the location(s) of any work zones as well as the EIC for each work zone.  Needless to say each person receiving a Train Bulletin is expected to read and comprehend what is printed on the Train Bulletin, this includes identifying any mistakes thay may exist in the Train Bulletin.  I suspect Amtrak has similar procedures.  If MofW do not complain of mistakes, it must be deduced that the work zone(s) identified on the Train Bulletin are in the proper form for the rules involved.

[wanswheel]

Excerpt from union’s letter to Joe Boardman, Apr. 13

http://www.pennfedbmwe.org/docs/amtrak/Membership_letter_with_Boardman_attachment_20160414.pdf

 

On October 1, 2003, Amtrak management unilaterally took Roadway Worker Protection (RWP), Northeast Operating Rules (NORAC) and physical characteristics training and qualification from the engineering department and put it under the Human Capital Department. These positions were made management positions and some of the rank and file trainers accepted these positions. Up until this time the training was performed by rank and file engineering department employees who had practical experience and knowledge in the areas that they were teaching. The teaching was relevant and based upon practical experience.

 

Very few of the former engineering department rank and file trainers, if any, are left and the training is now provided by management "trainers" who have no practical experience working on the railroad. This book training without the practical experience is very poor. There are also instances where the information being taught is not correct. Recently, one of our senior foreman had to challenge a "trainer" when the trainer said the only time that shunt straps were to be applied to a track is when a piece of track equipment is on it for five minutes or more, which is clearly not supported by NORAC Rule 140-82. In another instance, with the same "trainer" and foreman the trainer said that employees only had a right to "challenge," and not refuse to work, when confronted with a situation in which they are ordered to work in violation of the RWP rules. This is clearly not the case and we have agreements that specifically state otherwise.

 

All references to the shunting rules were unilaterally removed from the RWP training and the RWP manual in July 2014. The shunting rules need to be returned to the RWP training and the manual. Everyone is trained on RWP, but not everyone is trained on NORAC. Shunting issues played a major role in the Chester accident and reducing the number of employees who are trained and have knowledge of the shunting rules is an error.

[tree68]

There is no NORAC Rule "140-82."  I conclude he means rules 140 through 182, which includes both foul time and instructions regarding Form D's.

I'll have to get my official copy of the rules out of my grip, which is in the back of the truck, to see it mentions shunts.  The version I found on the NTSB website makes no mention in the foul time rules (140, 141).

While there's no question that the shunt (or rather the lack thereof) was a factor here, the fact remains that had the necessary communication occured, this incident would not have.

I still feel he's trying to deflect blame on to the railroad, which says to me that an individual is probably to blame.

Here's NORAC Rules 140 and 141:

140. Foul Time

Foul Time may be issued only by the Dispatcher, or Operator when authorized by the Dispatcher.

a. Action Required

Prior to Issuance Before issuing or authorizing Foul Time, the Dispatcher must determine that no trains or other on-track equipment have been authorized to occupy the track segment to be fouled. In signaled territory, the Dispatcher must ensure that Stop Signals have been displayed and blocking devices applied to controls of switches and signals leading to the affected track. When trains are to be held at a TBS where blocking devices cannot be applied, the Dispatcher must issue Form D line 13 instructing the Operator to hold trains clear of the affected track.

b. Permission to Foul Permission to foul the track must include the following information:

1. Title and name of employee receiving foul time

2. Track designation

3. Track limits (between/at)

4. Time limits The receiving employee must repeat this permission and the Dispatcher or Operator must then confirm it before the Foul Time becomes effective.

c. Releasing Foul Time Once protection has been provided, it must be maintained until the employee who was granted the foul time has released the foul time. The release must include the employee's title and name, and the track designation and limits being released. This information must be repeated by the Dispatcher or Operator, and confirmed by the employee releasing the foul time before blocking devices are removed.

141. Inaccessible Track

Roadway Workers may establish working limits on a track not controlled by the Dispatcher or Operator, by making the track inaccessible at each possible point of entry through one of the following means:

1. A switch or derail aligned to prevent access to the working limits and secured with an effective securing device, and properly tagged. The effective securing device and tag may be removed only by direction of the employee in charge of the working limits.

2. A remotely controlled switch aligned to prevent access to the working limits and secured with a blocking device by the employee who controls the switch. Blocking device protection must not be considered in effect until it has been confirmed by the employee controlling the switch. Protection must be maintained until the employee who requested the protection has reported clear. 

3. A disconnected rail.

4. A flagman assigned to hold trains and equipment clear of the working limits. Movements within working limits may be made only with permission of the employee in charge.

I find no reference to "shunt" in any of these rules, although it's possible that Amtrak has made a change that only applies to them or via other publication.

[dehusman]

You probably won't find a shunt in those rules because you are probably looking at transportation employee rules (TE&Y) and they don't use shunts.  For shunts rules you have to look at the rules governing employees that use shunts, that would be engineering department rules.

[rcdrye]

The Amtrak employee timetable for the Corridor lists the Amtrak rules for Foul Time and Supplemental Shunting Devices under system rules 140-S1 and 140-S2, which apply in addition to NORAC rule 140.

[tree68]

The RWP manual for Keolis (MBTA?) references 140-S1 and 140-S2 to whit:

FOUL TIME (SI 140-S1 & SI 140-S2)

In the application of Rule 140, Foul Time information must be recorded by the Dispatcher or Operator issuing the foul time, and the employee requesting the foul time. The employee must use the prescribed form. This form must be retained for 7 days. If other employees are going to foul, then they must be shown or read a copy of the foul time.

When a track governed by block signal system or interlocking rules is fouled and foul time is issued by the Train Dispatcher for time limits greater than 30 minutes, the Foreman receiving the foul time must ensure at least one of the following safeguards prescribed below are taken prior to beginning work. When C&S assistance will be required as prescribed below, the Foreman must request this assistance prior to obtaining foul time.

When a crew is working under the authority of foul time for more than 30 minutes, the employee-in-charge must ensure signals governing movement toward the fouling area must be set to display their most restrictive aspect by one of the following methods:

1. If not fouling within a crossing circuit, apply shunting device(s). The employee-in-charge must verify that the track is shunted by either contacting the Train Dispatcher who must observe the shunt on the model board, or by contacting a qualified signal employee. Or,

2. If fouling within a crossing circuit at crossings equipped with automatic gates, remove the plug from the gates normal position in the emergency control box at the crossing for the track to be protected. Or,

3. Open or reverse a hand throw switch at the fouling site. This option does not apply to hand throw crossovers, or when switch is within a crossing circuit. Or, 4. If no cars or equipment are stored on the siding at the work site, remove the derail at that siding, if available. This option does not apply when the siding is within a crossing circuit.

A qualified signal employee must be contacted if none of the above methods can be used, or if fouling within interlocking limits.

Prior to releasing foul time, the employee-in-charge must ensure that all supplemental protection has been removed.

A shunt is just one of several options, depending on the location.  Note that there are times when a shunt cannot be used.  And if a shunt is used, it has to be verified by either the dispatcher or a signal worker.

Regardless - the bottom line appears to be a lack of communication.  Exactly who didn't communicate with whom remains to be seen.

[schlimm]

tree68

Regardless - the bottom line appears to be a lack of communication.  Exactly who didn't communicate with whom remains to be seen.

Exactly.  We only know with some certitude that it was human error committed by either of the shift EICs from the track crew or a dispatcher.

[BaltACD]

schlimm

tree68

Regardless - the bottom line appears to be a lack of communication.  Exactly who didn't communicate with whom remains to be seen.

Exactly.  We only know with some certitude that it was human error committed by either of the shift EICs from the track crew or a dispatcher.

If it was a Dispatcher error, the FRA would have been shouting that from the roof tops the day after the event.  The FRA loves to 'out' mistakes that happen at the top of the responsibility chain.

[zugmann]

BaltACD

The FRA loves to 'out' mistakes that happen at the top of the responsibility chain.

 

Somebody has to.

 

 

[dehusman]

For all the people rushing to say "shunts" or lack thereof are the problem, read the last paragraph of the rule:

Prior to releasing foul time, the employee-in-charge must ensure that all supplemental protection has been removed.

The 3rd trick employee in charge had foul time.

The 3rd trick employee in charge released the foul time.

If the 3rd trick employee in charge had put down shunts for his foul time, he would have REMOVED them when he gave up his foul time.

That's why shunts are not the cause of this accident.  The only way they would have helped is if the 3rd trick EIC violated the rules and left them on when he released his foul time.  If the 3rd trick EIC complied with the rules then whether he used shunts or didn't use shunts, the situation would have been EXACTLY the same when 1st trick started.

Are shunts a good idea to put down when there is foul time out there?  You betcha.  But they don't establish foul time.  They are put down AFTER you get foul time and are taken up BEFORE you release foul time.  The only time they are out there is during the foul time.  The key is foul time, not the shunts.

[BaltACD]

zugmann

BaltACD

The FRA loves to 'out' mistakes that happen at the top of the responsibility chain.

Somebody has to.

I understand that, what I am saying is that the FRA highlights those early in the process when they happen.  They have not been highlighted to date.

[Euclid]

If a shunt was not used in the case of this crash, was that a matter of human error?

[schlimm]

BaltACD

 

 

schlimm

tree68

Regardless - the bottom line appears to be a lack of communication.  Exactly who didn't communicate with whom remains to be seen.

Exactly.  We only know with some certitude that it was human error committed by either of the shift EICs from the track crew or a dispatcher.

 

 

If it was a Dispatcher error, the FRA would have been shouting that from the roof tops the day after the event.  The FRA loves to 'out' mistakes that happen at the top of the responsibility chain.

 

Specious, at best.   The point is that the NTSB has not made even a preliminary finding as to cause; they do not know, and neither do you.

[dehusman]

Euclid

If a shunt was not used in the case of this crash, was that a matter of human error? 

I will try this again and try to type very slowly so you can understand it.

The 3rd trick employee in charge had foul time.

The 3rd trick employee in charge released the foul time.

If the 3rd trick employee in charge had put down shunts for his foul time, he would have REMOVED them when he gave up his foul time.

That's why shunts are not the cause of this accident.  The only way they would have helped is if the 3rd trick EIC violated the rules and left them on when he released his foul time.  If the 3rd trick EIC complied with the rules then whether he used shunts or didn't use shunts, the situation would have been EXACTLY the same when 1st trick started.  The shunts not being applied is not human error and is not an "error" at all.  There was not foul time, so there wasn't any requirement for shunts, the only way shunts would have been there under with all the other circumstances is if somebody violated the rules.  

The error is that that people were occupying/fouling the main track without authority.  There is a strong possibility human error was involved in that.

 

[Euclid]

dehusman

There was not foul time, so there wasn't any requirement for shunts,...

Dave,

How do you know that there was not foul time during the first shift?  I am not contending that there was foul time.  I am just wondering how you know that there was not.