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AMTRAK VS. CSX CAYCE, SC 2 4 18 REPORT RELEASED 7 23 19

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Posted by Overmod on Monday, December 23, 2019 1:35 PM

Euclid
Point and call forces users to do things without being guided by habit. 

Au contraire, point and call (when conducted by workers who are not eagerly dedicated to executing the practice with Japanese-style salaryman zeal) rapidly subjugates the activity of looking carefully and critically around for mechanical arm and mouth movements.  Compare the situation with 'California rolls' in stop-sign enforcement, where watching for potential cops and concentrating on making your little 'dip' at every stop interferes with watching the road for actual problems.

Like 40-second mandatory vigilance reset, it's entirely the wrong psychophysical approach to the problem, and I think most cognitive scientists will agree.  A much better approach is that used in aircraft checklists, where mindful attention to small details is what the policy induces; rather than 'pointing and calling' there ought to be some positive action tied to the "stimulus" -- for example, when you see a white departure light, look carefully down the platform both ways.  But for heaven's sake, don't make it a repetitive gesture that can be done with background attention!

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Posted by Euclid on Monday, December 23, 2019 1:48 PM

Overmod
 
Euclid
Point and call forces users to do things without being guided by habit. 

 

Au contraire, point and call (when conducted by workers who are not eagerly dedicated to executing the practice with Japanese-style salaryman zeal) rapidly subjugates the activity of looking carefully and critically around for mechanical arm and mouth movements.  Compare the situation with 'California rolls' in stop-sign enforcement, where watching for potential cops and concentrating on making your little 'dip' at every stop interferes with watching the road for actual problems.

Like 40-second mandatory vigilance reset, it's entirely the wrong psychophysical approach to the problem, and I think most cognitive scientists will agree.  A much better approach is that used in aircraft checklists, where mindful attention to small details is what the policy induces; rather than 'pointing and calling' there ought to be some positive action tied to the "stimulus" -- for example, when you see a white departure light, look carefully down the platform both ways.  But for heaven's sake, don't make it a repetitive gesture that can be done with background attention!

 

I would tend to agree with you if point and call were nothing but habit. But the point is that it must done in a conscious way so as to not become habit. Indeed, the purpose of point and call is give an action a greater identity than just a remembered event that is indistinguishable from other indentical remembered events.  Point and call requires the proper performance to make it work.   

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Posted by zugmann on Monday, December 23, 2019 1:53 PM

Euclid
Point and call requires the proper performance to make it work.

And a culture that is not really found on this side of the pond.

 

It's been fun.  But it isn't much fun anymore.   Signing off for now. 


  

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

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Posted by 243129 on Monday, December 23, 2019 4:12 PM

Euclid
The National Transportation Safety Board determines the probable cause of this collision of trains was the failure of the CSX Transportation Corporation to assess and mitigate the risk associated with operating through a signal suspension, which eliminated system redundancy for detecting a switch in the wrong position.

Proper training.

Euclid
The CSX Transportation Corporation conductor failed to properly reposition the switch for the main track, which allowed National Railroad Passenger Corporation (Amtrak) train P91 to be routed onto the Silica Storage track where the standing CSX train F777 was located.

Poor vetting.

Euclid
Also contributing to the accident was National Railroad Passenger Corporation’s (Amtrak) failure to conduct a risk assessment prior to operating during a signal suspension."

Poor supervision.

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Posted by n012944 on Monday, December 23, 2019 4:30 PM

daveklepper

Exactly, Balt, and that is exactly why signal systems improved safety.  If the signal system had not been deactivated, the Amtrak engineer would have known that the switch was not set correctly.  And if it were not for EHH, CSX would have not permitted such a long time gap between removal of block signal protection before PTC implementation, or less likely, would have imposed special conditions, possibly a speed reduction for temporary dark territory or just on approaching switches.

 

 

As someone who has done signal suspensions for PTC upgrades with CSX prior to EHH, I can tell you that just about everything you posted is not true.

An "expensive model collector"

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Posted by 243129 on Tuesday, December 24, 2019 1:54 PM

Off TopicOff TopicOff Topic

Merry Christmas to all, friend and foe alike.Stick out tongue

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Posted by 243129 on Wednesday, December 25, 2019 7:12 AM

Big Smile

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Posted by MMLDelete on Wednesday, December 25, 2019 9:25 AM

243129

Off TopicOff TopicOff Topic

Merry Christmas to all, friend and foe alike.Stick out tongue

 

Yes Yes

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Posted by charlie hebdo on Wednesday, December 25, 2019 9:32 AM

243129

Big Smile

 

Smile And a Merry Christmas to all. 

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Posted by mvlandsw on Wednesday, December 25, 2019 10:33 PM

If I remember correctly Chessie System used to limit speed to 35 mph over facing point switches when running against the current of traffic without the benefit of signal indications. That might reduce the severity of some accidents but not prevent all of them.

Once when running with the current of traffic in this territory I came upon a stop and proceed indication. While proceeding in accordance with this indication I came upon a switch that was lined from the main track into a short spur track. The switch was locked but the keeper was so worn that the switch position could be changed with the lock in place. I assume that a vandal had moved it.

Trains were frequently run in this territory against the current of traffic even though there were two main tracks because #2 track was in poor condition. If a train was moving east instead of west as I was going, it would have been diverted into the spur with no warning.

Mark Vinski

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Posted by Euclid on Thursday, December 26, 2019 9:33 AM

The interesting point is that the conductor recalled with absolute certainty, the performance of a task that day that he never performed.  Only when he thought more about it after the collision, did the conductor realize that he never lined the switch back for the mainline.  He said something to the effect of that he was used to the practice of leaving such a switch open as they put the engine away.  Then it will be open for resuming work once the next shift starts.

Routine makes things easier to remember—but routine also blocks the memory of any departure from the routine. 

He also said he was confused about the switch identifications, and did not have a complete record of his use of the switches that night.

The little we know about the conductor’s character may be found in what he has said about failing to reline the switch for the mainline.  I find it strange that the conductor would have been so sure that he had restored the mainline switch.  This strikes me as indicating a person who is overly confident, but unable to live up to that assumed confidence. 

I can tell you that if I was the conductor, and my engineer had expressed the degree of doubt that this engineer did, I would have walked down to the switch to check it myself.  I cannot imagine the conductor stubbornly sanding only on the principle that he remembered what he did, considering the life and death consequences of being wrong. 

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Posted by 243129 on Thursday, December 26, 2019 11:34 AM

Euclid

The interesting point is that the conductor recalled with absolute certainty, the performance of a task that day that he never performed.  Only when he thought more about it after the collision, did the conductor realize that he never lined the switch back for the mainline.  He said something to the effect of that he was used to the practice of leaving such a switch open as they put the engine away.  Then it will be open for resuming work once the next shift starts.

Routine makes things easier to remember—but routine also blocks the memory of any departure from the routine. 

He also said he was confused about the switch identifications, and did not have a complete record of his use of the switches that night.

The little we know about the conductor’s character may be found in what he has said about failing to reline the switch for the mainline.  I find it strange that the conductor would have been so sure that he had restored the mainline switch.  This strikes me as indicating a person who is overly confident, but unable to live up to that assumed confidence. 

I can tell you that if I was the conductor, and my engineer had expressed the degree of doubt that this engineer did, I would have walked down to the switch to check it myself.  I cannot imagine the conductor stubbornly sanding only on the principle that he remembered what he did, considering the life and death consequences of being wrong. 

 

Well said!Yes

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Posted by Overmod on Thursday, December 26, 2019 6:05 PM

Euclid
I can tell you that if I was the conductor, and my engineer had expressed the degree of doubt that this engineer did, I would have walked down to the switch to check it myself.

If I remember correctly, one of the two of them was actually in the process of doing just that when Amtrak came through the switch and they scattered.  I think I may have commented on this back in one of the interminable threads about Cayce in the first few months after the accident.

If you need proof of wacky 'training' -- the idea of leaving the switch open as a convenience for the next crew, whether or not it poses a hazard to SOP operations on the main should the signal system go down ... for a wide and often unpredictable number of the reasons parts of signal systems can go down ... is all the real example you need.  To me this would be like the 21st-century equivalent of rejection of the Bishop coupling knife just to 'prove something' to your buddies.

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Posted by tree68 on Thursday, December 26, 2019 6:24 PM

This is why we announce, on the air, that such-and-such switch is reversed/normal.  Every member of the crew with a radio is now aware of the action.

Some regard it as unnecessary, but with our volunteer crews, some of whom only work a few times a year, it's a nice safeguard.  

 

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Posted by charlie hebdo on Thursday, December 26, 2019 7:04 PM

Overmod

 

 
Euclid
I can tell you that if I was the conductor, and my engineer had expressed the degree of doubt that this engineer did, I would have walked down to the switch to check it myself.

 

If I remember correctly, one of the two of them was actually in the process of doing just that when Amtrak came through the switch and they scattered.  I think I may have commented on this back in one of the interminable threads about Cayce in the first few months after the accident.

If you need proof of wacky 'training' -- the idea of leaving the switch open as a convenience for the next crew, whether or not it poses a hazard to SOP operations on the main should the signal system go down ... for a wide and often unpredictable number of the reasons parts of signal systems can go down ... is all the real example you need.  To me this would be like the 21st-century equivalent of rejection of the Bishop coupling knife just to 'prove something' to your buddies.

 

I think that your example gives even more weight to the need for better vetting - hire people who rate high on conscientiousness, even if they are as dull as ditch water.  Thorough training on procedures and frequent checks, i.e. real supervision, not some pro forma yearly ritual. 

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Posted by Euclid on Thursday, December 26, 2019 8:50 PM

charlie hebdo
 
Overmod

 

 
Euclid
I can tell you that if I was the conductor, and my engineer had expressed the degree of doubt that this engineer did, I would have walked down to the switch to check it myself.

 

If I remember correctly, one of the two of them was actually in the process of doing just that when Amtrak came through the switch and they scattered.  

 

The engineer was on his way to check the switch after telling the conductor that he (engineer) did not see the conductor line the switch back to the mainline.  And he felt he would have seen it if it actually happened.  So there was a disagreement between the conductor and the engineer as to the position of the switch.

This seems to have developed over some brief time.   Then as the Amtrak train was imminent, this disagreement heightened to the point where the engineer told the conductor that he would go and check the switch for himself.  But that is where time ran out 

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Posted by MMLDelete on Thursday, December 26, 2019 10:48 PM

But I think the report says that the engineer jumped off of the engine and ran to safety. And that the conductor ran from the cab to point futher back on the engine.

So I'm not clear on what happened. Except that the conductor screwed up really bad. He was "sure" about something which was not true.

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Posted by CMStPnP on Thursday, December 26, 2019 11:14 PM

BaltACD
Total man failure incident by the switcher crew; no excuses for their failures. I have no idea how or how much the liability issues will be adjudicated; I doubt that it will be in CSX's favor.  In the US anybody can sue anybody else for any reason they can think of - whether it will ever make it to Court is another matter entirely.

So I think we mentioned this issue during the discussion on Amtrak using TRE tracks in Dallas.    The agreement Amtrak has with the freight railroads is that no matter who is really at fault for the accident.......Amtrak assumes complete liability for the accident and the frieght railroad is immune from any lawsuits from Amtrak passengers.    Is this not the case?    I even think Congress put a lawsuit cap per passenger as well in this policy so that the entire Amtrak budget wasn't wiped out due to one Amtrak disaster in a year.

I think potentially Amtrak could sue CSX for damage recovery.....maybe?   However, the passengers on the train that suffered injury could not and had to file their lawsuits against Amtrak.    I thought that was the standard Amtrak liability agreement concerning accidents that involved passenger injury or death.

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Posted by 243129 on Friday, December 27, 2019 8:09 AM

charlie hebdo
I think that your example gives even more weight to the need for better vetting - hire people who rate high on conscientiousness, even if they are as dull as ditch water. Thorough training on procedures and frequent checks, i.e. real supervision, not some pro forma yearly ritual.

Amen.Wink

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Posted by charlie hebdo on Friday, December 27, 2019 8:13 AM

Liability in a civil tort case is not at issue, as the matter is settled by the Amtrak/host agreement. 

The question is responsibilities for what occurred with a view towards prevention, as Joe McMahon and others have said.

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Posted by Euclid on Friday, December 27, 2019 11:00 AM
Lithonia Operator

But I think the report says that the engineer jumped off of the engine and ran to safety. And that the conductor ran from the cab to point futher back on the engine.

So I'm not clear on what happened. Except that the conductor screwed up really bad. He was "sure" about something which was not true.

 
The engineer had left the engine and was walking forward to check the mainline switch.  During this walk, the Amtrak train showed up and lurched off of the mainline and into the open siding switch.  Upon seeing this, the engineer quickly moved to a safer place, more distant from the siding that he had been walking along. 
 
At the same time, the conductor had remained in their engine, sitting in the cab seat, and watching forward toward the mainline switch which the engineer was walking toward it for the purpose of checking how it was lined.  When the conductor saw the Amtrak train lurch off the mainline and into the siding, he got up and ran back along the walkway to the rear end of the engine.  He was knocked off of the engine upon impact from the Amtrak train. 
 
The switch position verification required all parties to agree that the switch was properly lined.  All parties were responsible.  At the point where it became apparent that the engineer and the conductor did not agree on the switch position, they had a problem.  But apparently, the dispatcher was notified that the switch was properly lined even though the engineer could not confirm that point, and also doubted it.
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Posted by Overmod on Friday, December 27, 2019 11:12 AM

Let's not forget the other 'elephant in the room' - the Government's emergency requirement that the switch locking be officially documented and 'signed off on' in writing, to eliminate precisely this kind of problem.  

We had the discussion, so I won't repeat it here.  But there's an actionable Federal offense involved in the train of actions which left that switch improperly lined... and fat lot of good their fancy procedure accomplished.

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Posted by tree68 on Friday, December 27, 2019 12:42 PM

Overmod
Let's not forget the other 'elephant in the room' - the Government's emergency requirement that the switch locking be officially documented and 'signed off on' in writing, to eliminate precisely this kind of problem.  

We run on dark territory.  When we give track back to the DS, one of the questions we have to answer is if all switches in main track territory are normal.

We used to sign off a SPAF (switch position awareness form), but dropped that requirement several years ago.  Even then, we didn't sign it off until we were back at the station, ten miles from the switches in question.

If they gave the track back to the DS, and said they had restored the switch, they have a problem.  Even more so if they had actually signed off on a SPAF, which CSX still uses, last I knew.

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Posted by charlie hebdo on Friday, December 27, 2019 2:01 PM

Overmod

Let's not forget the other 'elephant in the room' - the Government's emergency requirement that the switch locking be officially documented and 'signed off on' in writing, to eliminate precisely this kind of problem.  

We had the discussion, so I won't repeat it here.  But there's an actionable Federal offense involved in the train of actions which left that switch improperly lined... and fat lot of good their fancy procedure accomplished.

 

As they say,  "can't make a silk purse out of a sow's ear."  Training and supervision help,  but a rulebook(s) thicker than a dictionary won't overcome an individual's shortcomings, in this case a lack of conscientiousness and overconfidence. So I would make job-specific vetting much more vigorous. 

 I believe codifying almost everything is probably counterproductive. 

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Posted by MMLDelete on Friday, December 27, 2019 2:26 PM

No, the SPAF didn't prevent this particular accident. But who knows how many accidents it HAS prevented.

Cayce in no way shows that the SPAF is a bad idea. All it shows is that if people don't use a system in the way it was intended, it cannot provide that extra measure of safety.

The SPAF may have helped prevent disaster in many other cases; it seems like a good idea to me.

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Posted by 243129 on Friday, December 27, 2019 2:37 PM

charlie hebdo
. So I would make job-specific vetting much more vigorous.

Agreed! However, and I speak of Amtrak, the personnel to assess a candidate's acumen for railroad operations has been squandered by the arrogance of the company. If they are at all interested in a safe operation they must 'swallow' their arrogance and call upon experienced operations employees to vet prospective operations candidates.

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Posted by tree68 on Friday, December 27, 2019 4:00 PM

Lithonia Operator

No, the SPAF didn't prevent this particular accident. But who knows how many accidents it HAS prevented.

Cayce in no way shows that the SPAF is a bad idea. All it shows is that if people don't use a system in the way it was intended, it cannot provide that extra measure of safety.

The SPAF may have helped prevent disaster in many other cases; it seems like a good idea to me.

And it wasn't my intention to illustrate that the SPAF is a bad idea.  

LarryWhistling
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Posted by jeffhergert on Friday, December 27, 2019 8:11 PM

243129

 

 
charlie hebdo
. So I would make job-specific vetting much more vigorous.

 

Agreed! However, and I speak of Amtrak, the personnel to assess a candidate's acumen for railroad operations has been squandered by the arrogance of the company. If they are at all interested in a safe operation they must 'swallow' their arrogance and call upon experienced operations employees to vet prospective operations candidates.

 

Yes, we need to weed out those who might have a failure, possibly many years, in the future.  You won't be hiring very many.  Heck, you won't be hiring anyone - ever. 

But I've already had the feeling that no one in this day and age would meet the standards some want to set.  Actually, in a way I understand this.  Generally speaking, the attitude of many in the work force is different than it once was.  At all age levels and in those fairly new and those who have a lot of time in.   

Jeff

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Posted by BaltACD on Friday, December 27, 2019 8:13 PM

If Joe were vetting himself - he would not get hired.

Never too old to have a happy childhood!

              

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Posted by 243129 on Friday, December 27, 2019 9:16 PM

BaltACD

If Joe were vetting himself - he would not get hired.

 

You cannot help yourself can you?

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