Medical factual report
https://dms.ntsb.gov/pubdms/search/document.cfm?docID=448761&docketID=59509&mkey=92941
Appears to be Bad Communications between formen and dispatchers. Engineer was doing what he was directed to do and did not receive notice of the work zone. While he had drugs in system, they don't seem to have impaired his performance. Press jumps on word DRUG and goes crazy. Dispatcher didn't notify Engineer of possibility of foul at work site.
As I read this, the work zone clearance was released by the night foreman and no notice to train 89's crew was given that it needed to be aware of the work zone.
I live near the BNSF Chicago racetrack and the communications between the work crews, train crews, and dispatchers seem to be much more rigorous and by the numbers. I would not want to assume being able to work on track with trains approaching and passing me at more than 20 mph unless I had confidence that train crews were made aware of my presence and were instructed to obtain clearance to pass me.
Unfortunately the dead men cannot say why they thought they were ok to work on a live track.
Perhaps there needs to be a method for an employee in charge (EIC) to transfer his clearance to the next EIC without removing or interupting the clearance.
Looks like Amtrak may have some of the safety culture issues that WAMTA has.
My readings indicate there was a totally faulty job briefing between the Night MofW Foreman and the Day Foreman, that concluded when the Night Foreman released his Foul Protection via a cell phone when he was presumably off the property.
Had foul protection been authorized by the Dispatcher trains would have been held off the tracks upon which the protection applied. Just as Train Crews can't out think Dispatchers in the moves that will be made, the Dispatcher can't out think MofW in what MofW wants to do at any point in time. MofW either has foul time or they don't. If there is no foul time - Run Trains. Daylight Foreman knew he did not have Foul Time, but he had no knowledge that the Night Foreman had released Foul Time.
Comments were made that the MofW gang was waiting for the arrival of the back hoe operator. I appears that the back hoe operator arrived, fired up his equipment and occupied the track, without having any form of job briefing with any of his MofW supervisors.
There area serious flaws in the Safety Culture at Amtrak as demonstrated by this incident.
Never too old to have a happy childhood!
BaltACD My readings indicate there was a totally faulty job briefing between the Night MofW Foreman and the Day Foreman, that concluded when the Night Foreman released his Foul Protection via a cell phone when he was presumably off the property. Had foul protection been authorized by the Dispatcher trains would have been held off the tracks upon which the protection applied. Just as Train Crews can't out think Dispatchers in the moves that will be made, the Dispatcher can't out think MofW in what MofW wants to do at any point in time. MofW either has foul time or they don't. If there is no foul time - Run Trains. Daylight Foreman knew he did not have Foul Time, but he had no knowledge that the Night Foreman had released Foul Time. Comments were made that the MofW gang was waiting for the arrival of the back hoe operator. I appears that the back hoe operator arrived, fired up his equipment and occupied the track, without having any form of job briefing with any of his MofW supervisors. There area serious flaws in the Safety Culture at Amtrak as demonstrated by this incident.
Likely so. Heavy duty drugs (cocaine, oxy, codeine and morphine) with the two construction operators didn't help. Looks like Amtrak needs a lot more random screens.
C&NW, CA&E, MILW, CGW and IC fan
I think the FRA/NTSB will insist on a safety blitz.
schlimm Euclid So, what is the source for this information about the positive drug tests for the backhoe operator, Joseph Carter Jr., and supervisor, Peter John Adamovich? And why would this information not be included in the NTSB report linked at the top of this post? That information on the two operators was included in the report. Drugs included cocaine and oxycodone, morphine and codeine. I suggest you look beyond page 1.
Euclid So, what is the source for this information about the positive drug tests for the backhoe operator, Joseph Carter Jr., and supervisor, Peter John Adamovich? And why would this information not be included in the NTSB report linked at the top of this post?
That information on the two operators was included in the report. Drugs included cocaine and oxycodone, morphine and codeine. I suggest you look beyond page 1.
Yes I now see the reference in the report posted at the top of this page by wanswheel called the MEDICAL FACTUAL REPORT. It refers to positive drug tests of the engineer, backhoe operator, and supervisor.
Previously, I had only read the 13-page HUMAN PERFORMANCE GROUP CHAIRMAN’S FACTUAL REPORT. It mentions and details the positive drug test of only the engineer, and not of the backhoe operator and supervisor.
Perhaps this divided report is why some newspapers reported positive drug tests for the engineer, backhoe operator, and supervisor; while others reported a positive drug test for only the engineer.
Randy Stahl I think the FRA/NTSB will insist on a safety blitz.
"The theory that all negligence which causes serious disaster will always be found to have been more or less habitual is still worthy of respect."
from "Has GR&I No.5 passed Mill Creek?" written by Harold B. Norman from the January 1974 edition of Trains magazine.
Originally from the middle column of page 44 of the 1889* (Vol. 21) Railroad Gazette, appears to be under the "EDITORIAL ANNOUNCEMENTS" heading there.
*The Trains article says it relates to an 1888 accident - not surprising that the commentary didn't appear in print until early the next year.
- Paul North.
https://babel.hathitrust.org/cgi/pt?id=mdp.39015013053718;view=1up;seq=66
It shows that the railroads still have a problem with collisions with other trains and vehicles.
schlimm It shows that the railroads still have a problem with collisions with other trains and vehicles. humans.
It shows that the railroads still have a problem with collisions with other trains and vehicles. humans.
"HUMANS" You nailed it MC.
mudchicken schlimm It shows that the railroads still have a problem with collisions with other trains and vehicles. humans.
Hey, drawing red lines through another's post is rude. What is your solution to the "human" problem? Automation?
schlimm mudchicken schlimm It shows that the railroads still have a problem with collisions with other trains and vehicles. humans. Hey, drawing red lines through another's post is rude. What is your solution to the "human" problem? Automation?
So long as we are human we are fallible. However, starting and ENFORCING a Safety Culture goes a long way in minimizing human error.
I worked in B&O's Baltimore Terminal in the early 70's. If the terminal went 30 days without a reportable injury it was a minor miracle. In the 21st Century the terminal has gone a year with only one reportable injury; and not just in one single year. The change in the Safety Culture between the two periods in time is the reason. If one thinks and believes Safety First rather than safety fast the culture changes.
This incident with the Rule G failures alone highlights a lack of any safety culture on Amtrak.
Being this is South Philly you have to watch out for them back hoes its not a good idea to make a back hoe angry.
BaltACDI worked in B&O's Baltimore Terminal in the early 70's. If the terminal went 30 days without a reportable injury it was a minor miracle. In the 21st Century the terminal has gone a year with only one reportable injury; and not just in one single year. The change in the Safety Culture between the two periods in time is the reason. If one thinks and believes Safety First rather than safety fast the culture changes.
Doubtless true, but I wonder if it is also related to a likely decline in the number of workers there?
schlimm BaltACD Doubtless true, but I wonder if it is also related to a likely decline in the number of workers there?
BaltACD
Two things above the reduced number of employees. Second time around Baltimore was not the headquarters of the Employer, therefore most employees didn't have a contact in the Company leadership to protect them; The change in culture was REAL, company officials were measured more on their injury record and human factor incident records than on their efficiency records.
Helping to change the culture was a near total workforce turnover in a relatively short period of time. The 'old heads' didn't influence the young blood long enough for the old heads bad habits to become ingrained in the new work force.
The theory being that the financial effects of injuries and human factor incidents cost more than minor dips in efficiency. Don't know that I fully agree with the theory, but I am not in a position to view the comparitive bottom lines.
BaltACDThe theory being that the financial effects of injuries and human factor incidents cost more than minor dips in efficiency. Don't know that I fully agree with the theory, but I am not in a position to view the comparitive bottom lines.
Cogent analysis beyond the "offical story" of a spreadsheet. Thanks!
Thanks to Chris / CopCarSS for my avatar.
How do you think at 180 MPH? Now Navy Aircraft Deck hands do it all the time
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