EuclidSo then I don’t understand why a point is being made about the new shift not hearing the previous shift’s permission being canceled over the phone transmission.
Just another possibility amongst the many we've discussed here. No more or less a big deal than anything else.
As Balt points out, there likely were folks who were aware that the foul time had been cancelled. It appears that the word didn't make it all the way to the bottom.
Larry 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...
Norm48327 Euclid I don’t understand the issue about anybody not hearing the phone transmission. If the day foreman of the track crew did not hear the phone call that fouling permission had been retracted, does that mean that he is free to assume that it still exists from the previous shift? It seems to me that if this permission can be retracted during a shift change, it would be required that the next shift verify whether or not the permission is still in effect. For a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept. Nope! That would make the day shift foreman a fool.
Euclid I don’t understand the issue about anybody not hearing the phone transmission. If the day foreman of the track crew did not hear the phone call that fouling permission had been retracted, does that mean that he is free to assume that it still exists from the previous shift? It seems to me that if this permission can be retracted during a shift change, it would be required that the next shift verify whether or not the permission is still in effect. For a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept.
I don’t understand the issue about anybody not hearing the phone transmission. If the day foreman of the track crew did not hear the phone call that fouling permission had been retracted, does that mean that he is free to assume that it still exists from the previous shift?
It seems to me that if this permission can be retracted during a shift change, it would be required that the next shift verify whether or not the permission is still in effect.
For a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept.
Nope!
That would make the day shift foreman a fool.
Norm,
I agree that such a rule would be flawed and dangerous. I am just saying that if the day shift foreman is required to verify permission before starting, I do not see how anything about the previous permission would be relevant. So then I don’t understand why a point is being made about the new shift not hearing the previous shift’s permission being canceled over the phone transmission.
FRA ordering Amtrak Safety Stand down -
http://baltimore.cbslocal.com/2016/04/08/after-deadly-crash-amtrak-must-retrain-workers-on-safety/
Never too old to have a happy childhood!
Do we know if the Foreman that was killed was the EIC?
I am suspecting he wasn't, but had information from the EIC that foul time WAS NOT in effect and when he saw the backhoe operator on the track he took actions to get him off the track. Proper communications among ALL parties in a large gang can be a difficult proposition.
If foul time must continue until the employee who requested it releases it, is it customary to release it at shift change, in order to not have it last longer than necessary?
tree68 Amtrak uses NORAC, currently the 10th Edition. You can find them on-line.
Amtrak uses NORAC, currently the 10th Edition. You can find them on-line.
http://www.hubdiv.org/docs/signaling/NORAC.pdf
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.
Norm
tree68As Balt notes, the biggest problem appears to have been on the worksite and the failure of the two shifts to talk to each other. If the DS had information that the ongoing work would involve the track in question, then he/she probably should have questioned what was going on. It may also depend on what, if anything, the off-going EIC told the DS in terms what what could be expected for the day shift.
And until transcripts of the conversations are released we are not going to know what went wrong.
Euclid tree68 Euclid Which is pretty much where we're going with this. Just remember the common breakdown of "assume." Well the question I have goes to that point. Is it normal, acceptable procedure for the new shift to proceed under the assumption that fouling permission exits because they have not heard otherwise? Or must the new shift proactively, and independently confirm that they have fouling permission before starting work? What is the rule about that? If the rule mandates that the each shift must confirm fouling permission, then I don't see what the communcation from the crew reliquishing their fouling permission has to do with anything in this accident.
tree68 Euclid Which is pretty much where we're going with this. Just remember the common breakdown of "assume."
Which is pretty much where we're going with this.
Just remember the common breakdown of "assume."
Well the question I have goes to that point. Is it normal, acceptable procedure for the new shift to proceed under the assumption that fouling permission exits because they have not heard otherwise? Or must the new shift proactively, and independently confirm that they have fouling permission before starting work? What is the rule about that?
If the rule mandates that the each shift must confirm fouling permission, then I don't see what the communcation from the crew reliquishing their fouling permission has to do with anything in this accident.
Don't know about Amtrak MofW discipline procedures. On my carrier for Dispatcher's not transfering 'protection' and the details surrounding it's granting is a fireable offence - and I have seen it applied.
tree68 Euclid For a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept. Which is pretty much where we're going with this. Just remember the common breakdown of "assume."
Euclid For a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept.
EuclidFor a new shift to proceed under the assumption that fouling permission exists because they have not heard otherwise seems like a flawed concept.
In this area there are two radio channels commonly used - the road channel and the dispatcher's channel. Unless everyone goes over to the dispatchers channel, they wouldn't hear the communication between the EIC and the DS.
In and of itself, there is nothing wrong with the EIC talking to the DS by phone, be it cell or landline.
As Balt notes, the biggest problem appears to have been on the worksite and the failure of the two shifts to talk to each other.
If the DS had information that the ongoing work would involve the track in question, then he/she probably should have questioned what was going on.
It may also depend on what, if anything, the off-going EIC told the DS in terms what what could be expected for the day shift.
ACY From my reading of the incident, a call over the Company radio would have been heard by other employees, such as the day crew. Use of the private cell phone precluded this, and effectively deprived the day crew of useful information. There are good reasons for following prescribed communication protocols. It appears that the night supervisor should not have made the call in this way, and the Dispatcher should not have accepted it. Tom
From my reading of the incident, a call over the Company radio would have been heard by other employees, such as the day crew. Use of the private cell phone precluded this, and effectively deprived the day crew of useful information. There are good reasons for following prescribed communication protocols. It appears that the night supervisor should not have made the call in this way, and the Dispatcher should not have accepted it.
Tom
Company radios have their own issues. Both the field radios and the tranmitter/receivers that allow the Dispatchers to be a part of the conversations. To have effective communications, both parties need to be able to hear each other clearly - there are times (more frequent than the companies would like to admit to) when the company radio system does not support EFFECTIVE communications.
I don't know the effectiveness of Amtrak radio system in accident area. I do know a carrier the operates in same area has been having radio communications issues in the area. Coincidence? Or is this a radio resistant area (and they do exist for whatever the reason(s))
No matter the means of release of protection - the appearant lack of communications between the Night Foreman and the Day Foreman concerning the protection is paramount.
I don't see the cell phone use in and of itself as a problem. When used in a prescribed manner (job briefing, not performing any "active railroading", etc), there is no problem with cell phones. Given the past focus on them, though, it's not surprising such attention may be given.
I fear this will bring undue attention on cell phones. It appears the problem was not the cell phone use in and of itself - it was the timing of the call(s) made (or not made) and an apparent lack of face-to-face communication.
Euclid Tom, This says the train and backhoe were on the same track. I also see this article and others is starting to mention cell phone use as you mention. I think this wreck is going to focus on an issue of safety culture. http://www.cortezjournal.com/article/20160407/AP/304079793/AfterAmtrakworkerskilledincrashfederalregulatorsordersafetyreview "The video showed there was construction equipment on the track and work train equipment on the track immediately adjacent to the Amtrak train's track," NTSB investigator Ryan Frigo said. "The backhoe was on the track where the Amtrak train was traveling."
Tom,
This says the train and backhoe were on the same track. I also see this article and others is starting to mention cell phone use as you mention. I think this wreck is going to focus on an issue of safety culture.
http://www.cortezjournal.com/article/20160407/AP/304079793/AfterAmtrakworkerskilledincrashfederalregulatorsordersafetyreview
"The video showed there was construction equipment on the track and work train equipment on the track immediately adjacent to the Amtrak train's track," NTSB investigator Ryan Frigo said. "The backhoe was on the track where the Amtrak train was traveling."
It is appearing that the critical element is becoming, What kind of turnover did the Night Foreman have with the Day Foreman and specifically, what was the Day foreman told about any protections that were or were not in place.
What I am putting together, from the bits and pieces that are being reported in the media, is that there was virtually no communication between Night Foreman and Day Foremen. The Night Foreman left the property and then called in on his private phone to release the protection he was carrying. The Day Foreman, may or may not have contacted the Dispatcher for protection - if he did, he found out one of two things, protection was in place in the name of the Night Foreman or there was No Protection in place as the Night Foreman had released it.
Incident took place at approximately 8 AM; historically MofW shifts start at 7 AM (most all of the railroad crafts that operate shifts use 7AM - 3PM - 11PM as the shift starts)
I don't think I've seen any coverage that precisely explains the position of the backhoe, but it appears that it was on the adjacent track or between that track and the Palmetto's track. It appears that the boom struck across the front of the locomotive and spun it around to strike windows on the first Amfleet car.
There is a current discussion on the Amtrak Unlimited site in which a forum member mentions a current article in Wall Street Journal. Evidently, that article says the track had protection during the time that the night work crew was there, but that protection was released at shift change. However, the article says the employee used a cell phone for this communication with the dispatcher, rather than an Amtrak radio. If the radio had been used, the incoming work crew would have heard the communication and known the track was no longer protected. It appears that the incoming crew thought the protection was still in effect.
If this information is correct, it looks like the dispatcher and night crew employee in charge should not have communicated by cell phone; and the day crew should not have interpreted lack of information to the contrary as an indication that the track continued to be protected.
Plenty of blame to go around.
When I see gangs working on the three track BNSF racetrack, even if they are only on one track, there are red flags on all three tracks on each boundry of the work zone and I see and hear on the radio trains calling the EIC for clearance to enter and pass the crew. Usually, the EIC gives clearance to proceed at track speed, but they sometimes they request a lower speed or that the train wait for clearance. I have never seen or heard a train ignore the work zone. I suspect that since the amtrak was doing 106 mph, the engineer probably never saw any markers nor did he have notice to make any radio contact with the EIC and that the dispatcher had not established a protected zone. Or is it routine to have a work zone and not include the adjacent tracks? I sure would not want trains passing me at 110 mph without being aware of them.
Still suspect that the new (1st trick) shift failed to renew the work zone after it was released by the third trick shift.
An interesting article about shunts.
http://www.philly.com/philly/blogs/in-transit/Amtrak-train-crash-mirrors.html
As information comes out more questions appear. It may be the overnight shift had a block on track #3. The supervisor released the track 3 and maybe even track 4 then left work scene before the next shift supervisor came on duty. Did the overnight supervisor leave because of HOS limitations ? Maybe the overnight super should have waited for day super to transfer track time ?
This work zone appears to have started Friday night and supposed to continue until very early Monday morning ? If the Loram on track 4 did not shunt the track maybe the dispatcher did not even know that there was a work zone there. The 106 MPH speed of train #89 on the adjaecent track #3 makes one wonder since track speed is not supposed to be allowed when adjaecent tracks are less than 20 feet ?
Euclid tree68 I'm still back at the point that the backhoe fouled the active track. That doesn't mean the backhoe was on the tracks - only that it was fouling. Unless I've missed something - was there even a need to get foul time on the active track? Did the trackhoe operator simply move outside the already authorized work zone? I saw an article last night that said that the backhoe was on the same track as the train, and the writer said it was therefore a "head on" collision. If the backhoe was on one track and fouling a second track, wouldn't it need foul protection for both tracks? At this point, I assume that either the backhoe operator mistakenly fouled a track for which he had no foul protection; or the somewhere else in the chain of communications, foul protection was removed from the backhoe without the operator and others on the ground being aware of that removed protection.
tree68 I'm still back at the point that the backhoe fouled the active track. That doesn't mean the backhoe was on the tracks - only that it was fouling. Unless I've missed something - was there even a need to get foul time on the active track? Did the trackhoe operator simply move outside the already authorized work zone?
I'm still back at the point that the backhoe fouled the active track.
That doesn't mean the backhoe was on the tracks - only that it was fouling.
Unless I've missed something - was there even a need to get foul time on the active track? Did the trackhoe operator simply move outside the already authorized work zone?
I saw an article last night that said that the backhoe was on the same track as the train, and the writer said it was therefore a "head on" collision. If the backhoe was on one track and fouling a second track, wouldn't it need foul protection for both tracks? At this point, I assume that either the backhoe operator mistakenly fouled a track for which he had no foul protection; or the somewhere else in the chain of communications, foul protection was removed from the backhoe without the operator and others on the ground being aware of that removed protection.
I am willing to bet, the supervisor that was killed knew the backhoe was not authorized on the track it occupied and was taking actions to have the backhoe operator get the backhoe off the track. Work gangs consist of up to and maybe exceed 100 people, the EIC cannot have personal communications with each person in the gang, at best he can have contact with supervisors that have responsibility for various work areas of the gang, it then becomes those supervisors responsibility to advise their people of what the working constraints are.
Norm48327Can he, through the dispatcher, convey that protection to the foreman of the releiving shift or would he have to close his protevtion and the new foreman secure his?
Unlike the Form D we are issued to operate a train, which is issued to the "conductor & engineer" (C&E) of the train - not specific individuals - track permission like this would generally be issued to an individual. I don't recall any mechanism in NORAC to do the transfer you suggest.
We routinely give up our track so another train can use it almost immediately. As often as not, this is done by phone, with the two conductors standing side by side. One cancels, the other takes the phone and gets their paper for their train.
Euc - If the backhoe was working on the track in question without foul time or another blocking procedure in place, then someone screwed up by not securing that permission from the dispatcher. The question there is why, as we have been discussing.
If the backhoe was otherwise clear of the track in question but fouled it by encroaching on it (boom, bucket), or even if he drove the backhoe onto the track in question, the question then becomes whether the operator erred by fouling the active track, or whether the track should have been protected and wasn't, potentially leading the operator to believe he could foul.
There are still a lot of unknowns here, most of which we won't have an answer to until the final report is filed or someone decides to let the information out.
tree68Unless I've missed something - was there even a need to get foul time on the active track? Did the trackhoe operator simply move outside the already authorized work zone?
If the workers were going to foul the adjacent track (whether they were "on" the track or "fouled the track" doesn't really matter, the regs use the term fouling) they should have some sort of protection established.
The backhoe operator is supposed to only be in the authorized work zone. So the question still not answered is did he think he was in an authorized work zone and wasn't, or did he knowingly go outside the authorized work zone. It would not be his responsibility to establish the work zone (EIC responsibility) but he has a responsibility to know where the work zone is and remain inside it. Unfortunately the guy who knows what he was told (the driver himself) and the guy who probably told him (his supervisor) are both tragically victims.
Dave H. Painted side goes up. My website : wnbranch.com
Question for Balt, and I know his answer may not be applicable to Amtrak.
Foreman of track gang A secures track time in the proper manner for the duration of his shift. Can he, through the dispatcher, convey that protection to the foreman of the releiving shift or would he have to close his protevtion and the new foreman secure his?
I hope that question is not confusing. The situation at hand makes me wonder if there were possibly a gap in protection.
dehusman PTC keeps trains out of established work zones. If no work zone was established then PTC would not prevent anything. If there is no physical warning or signal warning (work crew responsibility) then there is no back up. All the argueing about PTC is really a red herring. Anything that would have made PTC, as it is currently configured, work would have made things work safely even without PTC.
PTC keeps trains out of established work zones. If no work zone was established then PTC would not prevent anything. If there is no physical warning or signal warning (work crew responsibility) then there is no back up.
All the argueing about PTC is really a red herring. Anything that would have made PTC, as it is currently configured, work would have made things work safely even without PTC.
I am not so sure about that. Currently there is the protocol that you have outlined that depends on proper communication and is subject to human error. But I doubt that PTC would be completely dependent on the proper working of that human communication system. If it did, what good would it do? The point of PTC is to override that type of human system.
If PTC simply depended on those human inputs, why add wireless position and communication equipment directly to the backhoe, as has been mentioned in the news coverage?
As I understand PTC, it is a backup to all the rules and signalized methods of train control. So, while it is redundant, it amounts to a second guarantee, hence the word “positive” in Positive Train Control.
So the point is that even though all the rules and protocol about protecting work zones amounts to an infallible method, it can nevertheless fail if a mistake is made by human error in its execution. Apparently this accident clearly demonstrates that failure in practical human error of the perfect protocol in principle.
Considering this, I don’t think PTC is a red herring at all. If anything, it is a hot potato.
wanswheel Right, but consumers of red herring believe the train should stop even if the engineer is sound asleep.
Right, but consumers of red herring believe the train should stop even if the engineer is sound asleep.
Red Herring manufacturers have been working overtime with with everything going on - on the railroads, with other manufacturing and construction accidents and politics.
The way shunts would have worked assuming that the 3rd trick EIC would have gotten foul time, and applied shunts, at shift change if if the 3rd trick EIC gave up the foul time AND didn't remove the shunts (which would technically be a failure on his part since if he is giving up the foul time he should be removing the shunts), then at the start of first trick there would be no foul time. There would be a track occupancy in the block. The dispatcher would have seen the occupancy and would have challenged the EIC regarding what was going on with an occupancy in a track in which he had no authority. Since there was an occupancy the dispatcher wouldn't have lined the train into the block. With there being an occupancy the signal system would have had some restrictive signal into the block, if not a stop. All this without PTC. The processes in place for the last 50 years would have prevented it.
If the 3rd trick EIC in fact had foul time, had a shunt, then gave up the foul time and as part of the release of the foul time removed the shunt, then the situation would not have changed.
The real crux of the whole thing keeps pointing to the question of what did the 1st shift EIC do, what did he tell his people, and what action did they take.
If the 3rd trick EIC gave up the foul time (and even removed the shunts) that isn't necessarily unsafe. The point at which it becomes unsafe is if the 1st trick workers occupied the adjacent track before protection was established or without verifying protection was established. PTC keeps trains out of established work zones. If no work zone was established then PTC would not prevent anything. If there is no physical warning or signal warning (work crew responsibility) then there is no back up.
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