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Amtrak 501 Derail in Washington State

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Posted by Euclid on Saturday, August 25, 2018 9:34 AM

Coffee

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Posted by Euclid on Saturday, August 25, 2018 9:36 AM

243129
 
Euclid

 

 
243129

So what do you folks think will be contained in the final NTSB report as to the cause(s) of this disaster?

 

 

I do not expect them to place any blame on the institution of Amtrak such as inadequate training.  I also do not expect them to blame the engineer.  They will say that he was doing the best he could under the unfortunate circumstances.

I would really like to hear their explanation of the engineer's decisions regarding his method of braking as he realized he was approaching the curve way too fast. The NTSB has apparently contributed to confusion over those details by first reporting that the engineer made an application of the independent brake.  Assuming that was not the case, I would like them to explain their conclusion that it was.  The key point I would like to know is the derailment speed for that train entering the curve, and whether maximum braking starting upon the engineer's relization of the circumstances, would have prevented the derailment. 

I would like to know whether the brake application was mostly ineffective, as the engineer has stated, and if so, why?

The engineer spoke of passenger disruption such as spilled food and drinks from excessive speed on the curve.  He also said he thought that would be the extent of the problem.  At the final moment, the engineer said, "Aw, we're dead."  Prior to that point, did the engineer realize the high probability of derailing?  I would like to hear the NTSB's insight into that point.

I doubt that any of these details will be in the report.  So that leaves only the intense focus on the need for PTC.  I also expect the NTSB to place most of the blame on the curve for being too sharp.   

 

 

 

It really makes no difference whether or not the curve was/is too sharp. It is there,he knew about it, he failed to take action.

I stand by my previous observations of poor training, poor supervison and poor vetting as contributing causes. Amtrak is indeed culpable. 

 

I agree with that.  I am only referring to how the NTSB will see it and report it.

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Posted by 7j43k on Saturday, August 25, 2018 11:03 AM

Euclid

 

 
243129

So what do you folks think will be contained in the final NTSB report as to the cause(s) of this disaster?

 

 

I do not expect them to place any blame on the institution of Amtrak such as inadequate training. 

 

From the NTSB report on the 2016 Chester PA crash:

 

"Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety."

 

So, since they have done just that previously, why do you think it would change, now?

 

Ed

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Posted by Euclid on Saturday, August 25, 2018 12:04 PM

7j43k
 
Euclid

 

 
243129

So what do you folks think will be contained in the final NTSB report as to the cause(s) of this disaster?

 

 

I do not expect them to place any blame on the institution of Amtrak such as inadequate training. 

 

 

 

From the NTSB report on the 2016 Chester PA crash:

 

"Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety."

 

So, since they have done just that previously, why do you think it would change, now?

 

Ed

 

 

I had forgotten about that wreck and the report.  Maybe NTSB will cite a poor safety culture as being the cause of the 501 wreck.  Have they come to that same conclusion in the reports of any other railroad accidents?  So do we all agree that Amtrak has a poor safety culture?  I had the vague impression that that point was not fully agreed upon in this discussion.  Wasn’t it refuted by statistics showing an improving safety record?

 

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Posted by BaltACD on Saturday, August 25, 2018 12:43 PM

Euclid
Wasn’t it refuted by statistics showing an improving safety record?

Per Mark Twain - There are lies, damn lies and then statistics.

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Posted by Euclid on Saturday, August 25, 2018 1:20 PM

zugmann
 
Euclid
I think the most effective approach would be something like what Joe has done with his direct letters. Those communications have the feel of someone who has gone way beyond the simplistic and pointless plattitudes.

 

No they don't.  They have the feel of a someone who regretted retiring and now wants to be back in the game.   They are long-winded and rambling, and offer very few specific points.  Just "there were wrecks" and "I can make amtrak great again - ask me how!".

That may be the way he comes across to you, but that is just your perception.  Obviously the editor of Railway Age thought Joe made valid points.  If not, I doubt he would have run this article:

https://www.railwayage.com/news/guest-blog-amtrak-another-accident-waiting-to-happen/?RAchannel=home

His article is not long winded and rambling, or lacking in specificity, both as you say he is.

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Posted by zugmann on Saturday, August 25, 2018 1:25 PM

Euclid
Obviously the editor of Railway Age thought Joe made valid points.

And that was his perception.  And it's no wonder *you* think Joe's article was not long-winded. 

  

The opinions expressed here represent my own and not those of

my employer, any other railroad, company, or person.

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Posted by Euclid on Saturday, August 25, 2018 2:00 PM

zugmann
 
Euclid
Obviously the editor of Railway Age thought Joe made valid points.

 

And that was his perception. 

 

Well the point is that his points will be perceived differently by different people, but your "no they don't" response sounds like an assertion that everyone will perceive them the way that you do. 

I would also not automatically conclude that Amtrak dismissed his comments because they were not properly presented, or that his walking out on their meeting means that Amtrak has permenently closed the door on any further consideration.  These are merely viewpoints of certain individuals here. 

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Posted by Anonymous on Saturday, August 25, 2018 2:37 PM

Euclid
That may be the way he comes across to you, but that is just your perception. Obviously the editor of Railway Age thought Joe made valid points. If not, I doubt he would have run this article:

It is not only Zugmann's perception. As in the letters all you read are accusations not one substantial approach towards solutions. As Joe said in this thread more than once, he wouldn't disclose them as Amtrak might use them and call them their own.

It is not the content of the letters but their rude style that lets the recipients get the impression Zugmann describes.

Railway Age couldn't care less about the style. They are the transmitters not the addressee.

I have been on both sides of this "game" as project manager for structural design for Germany's largest construction company. On one side as addressee for ideas and requests from construction sites and clients and on the other side in need to sell solutions to the same parties. Letters in Joe's style or Big Boy talk wouldn't have opened one of the party's doors.

At this point we have been already 20 pages back.
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Posted by Anonymous on Saturday, August 25, 2018 3:00 PM

Euclid
Well the point is that his points will be perceived differently by different people, but your "no they don't" response sounds like an assertion that everyone will perceive them the way that you do.

It is only interesting how the recipients, Amtrak's managers and all others, perceived the letters. Their actions or better non-actions explain what they thought of the letters.

Euclid
I would also not automatically conclude that Amtrak dismissed his comments because they were not properly presented, or that his walking out on their meeting means that Amtrak has permenently closed the door on any further consideration. These are merely viewpoints of certain individuals here.

Amtrak must be dumb if they hadn't realized the accidents. On the other hand they for sure know the FRA statistics that show a steady decline in human error related accidents over the last 20 years. They might be sure that their hiring procedures are adequate in light of the statistic. The letter didn't tell anything new and offered solutions both in an offending way.

You seem to be one of the very few who see it differently, but perhaps you haven't been in such a situation. Your "certain individuals" have been or know enough about psychology to guess others reactions.
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Posted by 7j43k on Saturday, August 25, 2018 3:09 PM

Euclid

 

 
7j43k

From the NTSB report on the 2016 Chester PA crash:

 

"Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety."

 

So, since they have done just that previously, why do you think it would change, now?

 

Ed

 

 

 

 

I had forgotten about that wreck and the report.  Maybe NTSB will cite a poor safety culture as being the cause of the 501 wreck.  Have they come to that same conclusion in the reports of any other railroad accidents?  So do we all agree that Amtrak has a poor safety culture? 

 

 

I would have had to read all of their accident reports to say whether they came to that conclusion in "any" other.  And I have not.

As far "we" all agreeing that Amtrak has a poor safety culture, that, again, might be a leap.

I will say that I am not impressed with some of their management style, which would include safety.  I am also unimpressed with other organizations.

 

 

  I had the vague impression that that point was not fully agreed upon in this discussion.  Wasn’t it refuted by statistics showing an improving safety record?

 

Unfortunately, the improved safety record did not keep two men from being killed.  And it should have, shouldn't it?

 

 

Ed

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Posted by Euclid on Saturday, August 25, 2018 4:05 PM

7j43k
  Unfortunately, the improved safety record did not keep two men from being killed. And it should have, shouldn't it? Ed

Maybe the improving safety record has suddenly taken a "U"-turn as the retirement of older engineers reaches critical mass in ushering in a new style of safety culture and safety training.  And therefore, maybe the improving safety record is behind the curve in stating the actual safety status at Amtrak.  Maybe we have just begun the downward spiral of degrading safety as the product of the new, modern, safety culture.

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Posted by zugmann on Saturday, August 25, 2018 4:17 PM

Euclid
Maybe the improving safety record has suddenly taken a "U"-turn as the retirement of older engineers reaches critical mass in ushering in a new style of safety culture and safety training. And therefore, maybe the improving safety record is behind the curve in stating the actual safety status at Amtrak. Maybe we have just begun the downward spiral of degrading safety as the product of the new, modern, safety culture.

Maybe.  Maybe not.

  

The opinions expressed here represent my own and not those of

my employer, any other railroad, company, or person.

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Posted by Euclid on Saturday, August 25, 2018 4:22 PM

VOLKER LANDWEHR
 
Euclid
Well the point is that his points will be perceived differently by different people, but your "no they don't" response sounds like an assertion that everyone will perceive them the way that you do.

 

It is only interesting how the recipients, Amtrak's managers and all others, perceived the letters. Their actions or better non-actions explain what they thought of the letters.

I would tend to think that it would be difficult to get Amtrak to consider your suggestions if you confront them in a way that they consider to be hostile.  But we really do not know how they reacted or how many were involved in a way that would require a reaction.  That is nothing more than personal assumptions cooked up in this thread by those who may simply want to defend Amtrak from any criticism.  The only people who could state the Amtrak reaction to Joe's letters would be Amtrak themselves. 

However, the larger point that I see is that Amtrak is going to be the very last entity to react with any sort of approval for someone who wants to correct the way they manage safety.  So, I would say confrontation with Amtrak is the most powerful tool avaiable.  Just don't use it to try to get Amtrak to approve of your proposal to fix their problem.  As I have said before, take the message of Amtrak incomeptence to the public and to government.  If it has any chance of getting traction, that is where it will come from.   

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Posted by Deggesty on Saturday, August 25, 2018 4:24 PM

Euclid

 

 
7j43k
  Unfortunately, the improved safety record did not keep two men from being killed. And it should have, shouldn't it? Ed

 

Maybe the improving safety record has suddenly taken a "U"-turn as the retirement of older engineers reaches critical mass in ushering in a new style of safety culture and safety training.  And therefore, maybe the improving safety record is behind the curve in stating the actual safety status at Amtrak.  Maybe we have just begun the downward spiral of degrading safety as the product of the new, modern, safety culture.

 

None of the above?

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Posted by Anonymous on Saturday, August 25, 2018 4:26 PM

Euclid
Maybe the improving safety record has suddenly taken a "U"-turn as the retirement of older engineers reaches critical mass in ushering in a new style of safety culture and safety training. And therefore, maybe the improving safety record is behind the curve in stating the actual safety status at Amtrak. Maybe we have just begun the downward spiral of degrading safety as the product of the new, modern, safety culture.

It has nothing to do with your description. It is as often connected with the statistic. The statistic counts the numbers of the accidents independent of the consequences. And that is correct as it is intended to control the evolution for single causes not their results.A human error can have small or heavy consequences. You need to eliminate the errors and the consequences disappear too.

Take Amtrak 501. Had the engineer realized his mistake 10 seconds earlier he might haven gotten away with it, but it would still have been the same human error.
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Posted by Euclid on Saturday, August 25, 2018 5:23 PM

VOLKER LANDWEHR
 
Euclid
Maybe the improving safety record has suddenly taken a "U"-turn as the retirement of older engineers reaches critical mass in ushering in a new style of safety culture and safety training. And therefore, maybe the improving safety record is behind the curve in stating the actual safety status at Amtrak. Maybe we have just begun the downward spiral of degrading safety as the product of the new, modern, safety culture.

 

It has nothing to do with your description. It is as often connected with the statistic. The statistic counts the numbers of the accidents independent of the consequences. And that is correct as it is intended to control the evolution for single causes not their results.A human error can have small or heavy consequences. You need to eliminate the errors and the consequences disappear too.

Take Amtrak 501. Had the engineer realized his mistake 10 seconds earlier he might haven gotten away with it, but it would still have been the same human error.
Regards, Volker

 

I do not see what is is about my description that conflicts with what you descibe.  What I am saying is that perhaps Amtrak has suddenly turned a corner that is leading them into a rash of bad accidents, and the statistics have not caught up to reflect that turning of the corner.  So we are suddenly heading down a bad road and the statistics still say everything is fine. 

The 501 wreck alone looks like it will be a huge indicator of a worsening trend.  The wreck points to a cause in the highest institutional levels of Amtrak where they put their politics ahead of safety in rushing for a new startup that was not ready.  It is possible that this mistake is so big and obvious that it gets corrected today.  But it is probably more likely that it will not be corrected precisely because Amtrak will not accept the criticism or the blame. If that is the case, look for more dramatic crashes and a statistical record that is finally catching up with that worsening trend.  This is exactly what Joe has been talking about.     

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Posted by blue streak 1 on Saturday, August 25, 2018 7:26 PM

any internal operations for any compapny are jealously guarded as gospel.  

Food for thought.  What happened to Amtrak's "Safe 2 safe " ?

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Posted by 7j43k on Saturday, August 25, 2018 7:57 PM

Euclid

The 501 wreck alone looks like it will be a huge indicator of a worsening trend.

 

One wreck (or not) does not indicate anything about a "trend".

 

Ed

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Posted by Euclid on Saturday, August 25, 2018 8:06 PM

7j43k
 
Euclid

The 501 wreck alone looks like it will be a huge indicator of a worsening trend.

 

 

 

One wreck (or not) does not indicate anything about a "trend".

 

Ed

 

It does if it has the whole company culture as the cause of the wreck.  The "trend" is in that culture, and it will manifest as accidents

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Posted by 243129 on Saturday, August 25, 2018 9:16 PM

7j43k

 

 
Euclid

The 501 wreck alone looks like it will be a huge indicator of a worsening trend.

 

 

 

One wreck (or not) does not indicate anything about a "trend".

 

Ed

 

"One wreck"? Where have you been?

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Posted by 243129 on Saturday, August 25, 2018 9:17 PM

Remember this 'performance'?

"Amtrak workers have gone back to school after a New York City-bound train took a wrong turn and wound up in the Philadelphia suburbs on Thursday."

Guess they did not learn much at 'school' did they?

 

http://www.huffingtonpost.com/2013/11/20/amtrak-lost-philadelphia-septa-new-york-fiasco_n_4312239.html
http://www.dailymail.co.uk/news/article-2510563/Oops-NYC-bound-Amtrak-train-ends-Philadelphia-suburbs.html

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Posted by BaltACD on Saturday, August 25, 2018 10:06 PM

243129
Remember this 'performance'?

"Amtrak workers have gone back to school after a New York City-bound train took a wrong turn and wound up in the Philadelphia suburbs on Thursday."

Guess they did not learn much at 'school' did they? 

http://www.huffingtonpost.com/2013/11/20/amtrak-lost-philadelphia-septa-new-york-fiasco_n_4312239.html
http://www.dailymail.co.uk/news/article-2510563/Oops-NYC-bound-Amtrak-train-ends-Philadelphia-suburbs.html

Is 243129 the author of these articles?  The breathless contempt is palpable. 

Not knowing the specifics of the the territory it is hard to discern how big of a mistake was made.  While the UK's Daily Mail said several miles and indicated the train took a signal that was not proper for it; the HuffPost article stated the train had mechanical issues in Push mode with the Cab Car and was attempting to turn the train on a Wye.  How far past the clearance point of the Wye did the train go?  Since it would appear that continued operation on this leg of the Wye would lead to SEPTA trackage - Was there any communication between Amtrak Dispatchers and SEPTA Dispatchers about the move - at the very least to have SEPTA to block their signals to prevent movement into the track the Amtrak train was going to use.

Potentially a whole Efficiency Test booklet of failures for all concerned.

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Posted by 243129 on Saturday, August 25, 2018 10:16 PM

BaltACD

 

 
243129
Remember this 'performance'?

"Amtrak workers have gone back to school after a New York City-bound train took a wrong turn and wound up in the Philadelphia suburbs on Thursday."

Guess they did not learn much at 'school' did they? 

http://www.huffingtonpost.com/2013/11/20/amtrak-lost-philadelphia-septa-new-york-fiasco_n_4312239.html
http://www.dailymail.co.uk/news/article-2510563/Oops-NYC-bound-Amtrak-train-ends-Philadelphia-suburbs.html

 

Is 243129 the author of these articles?  The breathless contempt is palpable. 

Not knowing the specifics of the the territory it is hard to discern how big of a mistake was made.  While the UK's Daily Mail said several miles and indicated the train took a signal that was not proper for it; the HuffPost article stated the train had mechanical issues in Push mode with the Cab Car and was attempting to turn the train on a Wye.  How far past the clearance point of the Wye did the train go?  Since it would appear that continued operation on this leg of the Wye would lead to SEPTA trackage - Was there any communication between Amtrak Dispatchers and SEPTA Dispatchers about the move - at the very least to have SEPTA to block their signals to prevent movement into the track the Amtrak train was going to use.

Potentially a whole Efficiency Test booklet of failures for all concerned.

 

Six miles in the wrong direction. Not one person on the crew knew where they were. The only reason they did not go further is because the track ended.

Breathless contempt? Where do you deduce that?

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Posted by Anonymous on Sunday, August 26, 2018 3:39 AM

Euclid
I do not see what is is about my description that conflicts with what you descibe. What I am saying is that perhaps Amtrak has suddenly turned a corner that is leading them into a rash of bad accidents, and the statistics have not caught up to reflect that turning of the corner. So we are suddenly heading down a bad road and the statistics still say everything is fine.

Than you should perhaps read the statistic again. The number of human error caused Amtrak accidents was 2, IIRC. Not more than in the years before but much less than in the early 2000s.

If there were a turnaround there should have been more than 2 accidents.

Euclid
The 501 wreck alone looks like it will be a huge indicator of a worsening trend.

In the sense of the statistic the 501 wreck only shows that a human error can have fatal consequences, nothing more.

Euclid
The wreck points to a cause in the highest institutional levels of Amtrak where they put their politics ahead of safety in rushing for a new startup that was not ready.

Remember, the statistic wasn't used by its poster to clear Amtrak, nor do I. I understood the statistic as another indicator why Amtrak, in the light of the statistic, might not have seen the need to discuss ideas for improving hiring and vetting.

The statistic doesn't exclude that something  is wrong within Amtrak, it only shows that Amtrak got much better regarding human error accidents over the last 30 years. Perhaps not everything they did was wrong? That might have been their impression.

The devilish thing about human errors are that they can be without any consequences like a red signal violation or with fatal consequences like #501. Often happenstance decides which way.

Euclid
But it is probably more likely that it will not be corrected precisely because Amtrak will not accept the criticism or the blame. If that is the case, look for more dramatic crashes and a statistical record that is finally catching up with that worsening trend.

The statistic doesn't look into the future. It shows a trend of decreasing numbers human error accidents at Amtrak. Though numbers are lower than before there are two with heavy consequences which need watching to avoid that the trend reverses.

In the NTSB hearing Amtrak talked about implementing a safety management system. The system will only work with an open error culture. When you want to avoid mistakes the systems needs to learn of all of them. But employees won't report if they have to fear disciplinary consequenses. Does that work in the railroad industry?
Regards, Volker

 

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Posted by 243129 on Sunday, August 26, 2018 7:55 AM

Herr Landwehr: Tell the 53 families of the folks who were killed in the last ten years in human error caused accidents how statistics reflect that railroads are doing much better safety wise.

I would be willing to bet that you would get more than one GFY.

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Posted by 243129 on Sunday, August 26, 2018 8:13 AM

Here is a little more reading material for you Herr Landwehr.

https://www.msn.com/en-us/news/us/amtrak-crash-workers-say-they-warned-of-inadequate-training/ar-BBIlAbk?ocid=se

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Posted by Euclid on Sunday, August 26, 2018 8:57 AM

VOLKER LANDWEHR
 
Euclid
I do not see what is is about my description that conflicts with what you descibe. What I am saying is that perhaps Amtrak has suddenly turned a corner that is leading them into a rash of bad accidents, and the statistics have not caught up to reflect that turning of the corner. So we are suddenly heading down a bad road and the statistics still say everything is fine.

 

Than you should perhaps read the statistic again. The number of human error caused Amtrak accidents was 2, IIRC. Not more than in the years before but much less than in the early 2000s.

If there were a turnaround there should have been more than 2 accidents.

 
Euclid
The 501 wreck alone looks like it will be a huge indicator of a worsening trend.

 

In the sense of the statistic the 501 wreck only shows that a human error can have fatal consequences, nothing more.

 
Euclid
The wreck points to a cause in the highest institutional levels of Amtrak where they put their politics ahead of safety in rushing for a new startup that was not ready.

I refer to Amtrak’s new lapse in safety training as a “turnaround” or “U”-turn because it is a diametrical change in direction that is apparently quite recent.  Thus there has not been enough time for many accidents resulting from the turnaround.  But because the turnaround seems to head in a new direction that is prone to causing accidents, I would call that new direction a “trend” even though the number of accidents so far may be only a few, and thus not seem to be a trend on a statistical basis.

And that is the problem with statistics.  In the case of 501, the statistics show only the fatal consequences of one wreck directly caused by human error.  At the same time, those statistics utterly fail to show the institutional incompetence and wrongheaded safety culture of Amtrak that will be found to have played a far greater role in the cause of the accident than the engineer’s human error.  

I don’t have the full picture, but from widespread reporting, we have learned that Amtrak and perhaps other politicians rushed the startup of the new train in the face of inadequate crew training.  Incredibly, at the start of the first run, the engineer seems to allude to an issue of being unfamiliar with the route.

It appears that this Amtrak institutional failure leading to potential accidents may be developing much faster than the statistical record of accidents.  Amtrak’s internal problem is a leading indicator.  The statistical record is a lagging indicator.  So the news today may not be the twenty years of statistics showing everything is okay, but rather, a sudden and abrupt reversal of that trend.

And the reversal of one trend begins a new trend.

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Posted by 243129 on Sunday, August 26, 2018 9:19 AM
Well said Euclid.
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Posted by BaltACD on Sunday, August 26, 2018 9:32 AM

CNN
NTSB chairman Robert Sumwalt concluded: "Amtrak's safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management." He added, "investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate."

When you can't get management and unions to talk about safety issues, you have NO safety culture.  The S word has to mean something in the culture of the railroad.

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