EuclidI 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.
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.
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!
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
243129
And a Merry Christmas to all.
243129 Merry Christmas to all, friend and foe alike.
Merry Christmas to all, friend and foe alike.
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.
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"
EuclidThe 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.
EuclidThe 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.
EuclidAlso 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.
EuclidPoint 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
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!
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!
EuclidPoint and call forces users to do things without being guided by habit.
Cayce did not need switch tenders. It needed a way to separate the recall of a most recent action from all other previous actions that were identical to the most recent action. If the conductor had never thrown that switch in the past, except for once throwing it to line it for the main line, he would have never fogotten that act. The japanese system recognizes that human vulnerability of mixing up past identical actions. So their point and call is a technique to attach new symbols to those new actions so they are less likely to be confused with earlier identical actions. Point and call forces users to do things without being guided by habbit.
zugmannJapanese would have probably assigned a switch tender to each switch.
On CSX, at least the Baltimore Division, where crossovers were involved at the Control Point that was being updated, Switchtenders would be assigned to operate the crossovers at the Train Dispatcher's direction. Such switchtenders were to eliminate the need for a train to stop, throw their own switches when making a crossover move as well as being required to realign the crossovers to the Normal position after their use.
Crossovers were not involved in the Cayce incident.
Manpower has been a recurring problem in staffing switchtender positions.
Never too old to have a happy childhood!
Japanese would have probably assigned a switch tender to each switch.
BaltACDWhat you will find over and over again - sometimes even the 'best, most grounded, most rule compliant, most responsible' make mistakes.
It seems to me that the Japanese "point and call" technique acknowledges your assertion here. Point and call teaches employees to be aware of the possibility of making mistakes, and uses a technique of consciously recognizing that possibility, and constantly questioning whether a mistake is being made.
charlie hebdoSure, we all make mistakes. That's just an excuse, much like "s**t happens." I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
Start reading accident reports - all kinds of them - railroad, airline, pipeline and marine accidents.
What you will find over and over again - sometimes even the 'best, most grounded, most rule compliant, most responsible' make mistakes. Yes the undertained, undermotivated, sloppy, lackadaisical and bad employees make most of the mistakes. But mistakes are not the exclusive property of bad employees.
I am not making any assessment as to whether the CSX employees involved in the Cayce incident were either good or bad. They made the mistake - they have to live with the consequences.
"Less likely" will come into question when the apportionment of percentages of liability in a civil suit is made.
The NTSB lists four elements of the probable cause, apparently in order of importance. The first listed element of probable cause is the failure of CSX to assess and mitigate the risk of operating through the signal suspension.
From the report:
"Probable Cause
​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.
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.
Contributing to the accident was the Federal Railroad Administration’s failure to implement effective regulation to mitigate the risk of misaligned switch accidents. 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."
Lithonia OperatorIt sounds like one employee might be "more guilty" -- if such a concept even exists -- than the other, in real terms.
I would opine that the employee who failed to restore the switch would hold primary guilt. The engineer would basically be an accessory. By rule, however, both are guilty.
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...
charlie hebdo Sure, we all make mistakes. That's just an excuse, much like "s**t happens." I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
Sure, we all make mistakes. That's just an excuse, much like "s**t happens."
Of course. "Less likely." Absolutely. I doubt anyone would disagree.
But such individuals still make mistakes. In this case I know of no facts that point more at the trainers/supervisors than at the offending employees. (It sounds like one employee might be "more guilty" -- if such a concept even exists -- than the other, in real terms. But, job-wise, both are equally guilty, IMO.
Does anyone know of any supervisors/trainers getting fired over this incident? (I'm not contendig that would prove anything, btw.)
matthewsaggie In the end CSX will pay little, since if folks recall, Amtrak under their contracts with the carriers assumes all financial liability and indemnifies the carriers for their expenses no matter the cause. I dont recall hearing that this has changed in the past few years.
In the end CSX will pay little, since if folks recall, Amtrak under their contracts with the carriers assumes all financial liability and indemnifies the carriers for their expenses no matter the cause. I dont recall hearing that this has changed in the past few years.
Johnny
It sounds like NTSB is blaming CSX for operating with excessive risk.
If there is anyone who would be interesting to hear an explanation from, it is the conductor who failed to reline the switch in this collision. Are his interviews available as part of this NTSB accident report?
An interview is needed to provide insight into his state of mind. An interview of the engineer would also be helpful to understand how a single point could have been gotten so wrong when you have the formal switch position verification procedure and the full professional knowledge of how critical that one point was. Although, as I understand, the switch verification procedure had not been used by either the conductor or the engineer for quite some time, and it was only used at Cayce during the signal suspension.
As I recall, the conductor was seemingly unwilling to even consider that he had not relined the switch even with the engineer explaining to the conductor that he never saw the conductor reline it; and would have seen him reline it if he had done so. So prior to the collision, question of the switch position was laid on the table between the conductor and the engineer. It is my understanding that the crew was responsible for agreeing that the switch was properly lined for the passenger train.
Only when time was running out did the engineer’s doubt rise high enough to walk to the switch and check it. And, the conductor did not go with him. So there was a stark disagreement between the engineer and conductor about that position of that switch. Just because of that disagreement existing when the rules require full agreement; at that instant, they should have called the dispatcher and had the dispatcher stop the Amtrak train.
Stopping Amtrak should have taken precedence over checking the switch, because time for checking the switch had run out.
I agree with Balt. Job perfomance failures cannot always be chalked up to poor training or supervision.
A well-trained person can go for years performing exemplary service, then one day go to work after a bad night's sleep, or a death in the family, or having just learned their wife is having an affair, or whatever. They are distracted, exhausted. All of us have had days on the job where we got through the day on autopilot.
Or, we made mistakes; but they did not yield tragic results. Once I photographed and impatient, stuffy New York state senator ... then had to tell him I had forgotten to put film in the camera. No one died, even though I wanted to.
Anyone can make a mistake. Now, there is no excuse for the negligence of these CSX men. Even though the trainmaster may get pissed, if you are not fit for service you have to mark off.
Then there are people who were once great employees who eventually simply get bored and/or careless. This is not the fault of the person who trained them fifteen years before. This is not the fault of the supervisor who has noted their good performance all through the years. But then one day the carelessness, boredom, and complacency has consequences.
As for the Amtrak liability law, it certainly will be a travesty for Amtrak to have to eat this one, when the blame is 100% on the two CSX employees.
daveklepperExactly, 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.
Before I retired on my territory, we would have roughly one or two Signal Suspensions per month as Control Points were upgraded for the ability to support PTC.
Months before, signal construction gangs would perform the work of installing new foundations and other items necessary to install PTC supportable equipment - signal masts, signals, electronic cabinets etc. The suspensions would normally cover three adjoining Control Points at a time and be undertaken mostly on Friday's into the weekend. The middle of the three Control Points would be the one that was having its equipment upgraded. Most were completed within a 36 hour span of time from start to finish - which in reality would be two twelve hour days for the Signal Dept. employees as they are covered by Hours of Service regulations. If problems were encountered, the suspension could be in effect for a longer period of time - never exceeding 72 hours in my observations.
Announcement of the Signal Suspension would go out a 'Superintendents Bulletin' in the week before the scheduled date of the suspension. Starting about 16 hours prior to the effective date and time of the suspension, a point of contact (specified in the bulletin) is opened that ALL Crews going on duty that would be operating through or in the area defined by the suspension were required to contact the individual manning the contact point to discuss the specific requirements of what crews had to do in operating through, or in, the defined limits of the suspension. The contact point would be manned by either a local operating official for the area or a senior T&E craft employee that has demonstrated both the ability to communicate as well as fully understanding the rules in play and how those rules with apply to those crews operating within the limits of the suspension.
Once the suspension commences, the Train Dispatchers involved will be closely monitored by the Chief Dispatcher in the office on the issuance and release of the Track Warrant Authorities. The Signal Department would hire a 'Communicator' (normally a retired Chief Dispatcher, hired as a consultant) to act as intermediary to communicate the conditions signals requires to test various aspects of the new installation that the Train Dispatcher must set up by routing trains in specific ways through the limits of the suspension.
The Signal Suspension Bulletin would state that the signals at the first and third control points mentioned, while operating, would ONLY be conveying 'switch position' not movement authority - movement authority being conveyed by specific Track Warrant authority to the individual train(s). Trains would operate at the FRA speeds required of operation in DARK territory - 59 MPH for passenger, 49 MPH for freight.
When I was working on the Baltimore Division, pre EHH, Signal Suspensions were taken VERY SERIOUSLY by all concerned as it was understood that the field employees were being tasked with operating under a rules system they have had relatively little experience working under.
The Cayce incident happened on the Florence Division during the after EHH period - I have NO IDEA how that division was administrating their Signal Suspensions at the time of the incident.
243129 BaltACD Second you have to expect employees to comply with the most basic of rules. Poor training.
BaltACD Second you have to expect employees to comply with the most basic of rules.
Poor training.
I guess you were the trainer. I wasn't. In the world of human endeavor - even the best trained and exhaustively drilled still make mistakes. Something about the human condition not being 100% perfect 100% of the time. Failures in the railroad world have a high cost - in human lives and property damage. Property damage being secondary.
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