Perhaps this story from 1996 will be of interest ... or serve as added fuel ... in this discussion, with particular respect to engineers with 'the wrong stuff' in some ways:
https://www.nytimes.com/1996/07/22/nyregion/few-engineers-commit-most-of-rail-errors.html
charlie hebdoThe procedure of having a crucial speed restriction passed on to the conductor by the engineer so that the conductor can act as a fail-safe on the engineer is comical in its absurd circularity.
I think that in the 'old days' of passenger operation, the idea was that the conductor 'back in the train' would be watching the mileposts, and if he saw the train was coming up on a slow order or restriction at too high a speed he would pull the air to stop it. That would make somewhat better sense if the conductor's air were in fact either proportional or graduated, so that they could reduce speed in the manner of TVM, even right down to 10mph, without irrecoverably causing a 'penalty-brake' like full stop.
There's also the unavoidable conclusion that mandatory sharing of the order is also mandatory sharing of any eventual blame, a bit like making everyone working a shift in a Waffle House responsible for any shorting that turns up in the cash drawer. In my opinion such a thing should be universally condemned, no matter how expedient it may prove to be 'from time to time'.
Also, in this electronic age, both should be directly communicated with.
Where, of course, we collide squarely with the evil legacy of the railfan's friend whose accident was the major stimulus giving us the PTC mandate... and the ban on electronic devices on duty. It would be wholly logical to communicate slow orders through something as simple as datastream over pager frequencies, with the pager 'backchannel' being effective at acknowledging at least receipt. But this accomplishes only part of what the 'correct' imparting of safety-critical orders needs to involve, and any device to do this 'direct communication' would:
1) get the entire foreground attention of both engineer and conductor;
2) require acknowledgement that the message has been received, and is being read;
3) require that the order be read back, either 'word for word' or in plain language, the same being sent to a radio channel that is being recorded in voice with adequate quality;
to which we should fairly promptly add
4) the device should then provide adequate reminding to background attention when the time or place of the received order(s) is being approached -- e.g. by GIS/GPS following.
I humbly submit that any device capable of actually doing these things competently would be banned under current restrictions, and a device that isn't would be functionally worthless at assuring safety.
And what about PTC? Wouldn't a properly designed system prevent this?
A properly-designed set of systems that accomplished at least the four separate purposes contained in the mandate would probably contain the ability to transmit not only slow orders, but any emergent 'civil' consideration in any reasonably complex form desired. together with the redundant 'backchannel' bandwidth to acknowledge the order both in voice and from the electronic "train control" oversight systems.
As I noted, it's almost impossible to believe that critical slow orders wouldn't be fully (and nearly immediately) implemented by the display of a cab signal system. There are a couple of incidental 'gotcha' situations, like the one that produced the Highliner crash in 1972, but I don't find them insurmountable showstopping kinds of thing. As far as I know, PTC is designed to control either speed or braking in the 'civil safeguarding' mode, where presumably slow orders respecting track condition would be implemented. Certainly setting roadway-worker safety limits at some arbitrary mph is supported, and so any emergent restriction like the one in the present case could be 'updated' with whatever frequency the system supports, perhaps 'every six seconds' or more frequently, so that an order for 30mph at 1:00 is updated 'for everybody' when it changes to 10mph at 1:15 as someone in the field reports worsened kink.
Of course this rules out the original point being made here, which is that a slow order ought to be a warning with a reason behind it, and a slow order with a history of increasing restriction ought to be understood for the critical thing it is, more than just a note to watch out. I think much of how we look at this issue is concerned with the semantics of the actual order that was issued, and in where the procedures to issue and acknowledge came to appear to have been so badly perverted: while I squarely place responsibility on the engineer 'no matter what' (as Joe is saying) I also think he may have been ill-served by what, and how, he was told.
Whether or not the existing cobbled-up camel that is modern PTC would have effectively caught the revised speed decrease and operated on the two speeding trains is a technical discussion I can't speak definitively on. It's certainly better than nothing, which was the effective situation on the Metro-North New Haven line then, and may still be now.
Reading over the report, it appears that the medical monitoring for sleep apnea for engineer 1373 was inadequate. The monitoring for diabetes mangagement compliance was inadequate for engineer 1373. It certainly should have been much stricter, given that he had previously fallen asleep on duty.
The procedure of having a crucial speed restriction passed on to the conductor by the engineer so that the conductor can act as a fail-safe on the engineer is comical in its absurd circularity. Also, in this electronic age, both should be directly communicated with. And what about PTC? Wouldn't a properly designed system prevent this?
Overmod BaltACD So on Metro-North Slow Orders were a little deal. Got it. I know this is going to sound weird, and perhaps I'm looking in the wrong place or for the wrong thing ... but I can't find anything regarding issuance or acceptance of emergency slow orders anywhere in the 18th edition of NORAC. Neither can I find any 'safety instructions' for Metro-North that don't refer to personal employee safety of more or less actionable kinds. What is the precise Metro-North rule specifying the correct method of informing operating employees of critical slow orders related to track defects (rather than just trackwork or other maintenance-related zones)? And how is receipt of such an order supposed to be acknowledged, including the 'issuer's' reasonable assurance that the order has been communicated and received properly?
BaltACD So on Metro-North Slow Orders were a little deal. Got it.
I know this is going to sound weird, and perhaps I'm looking in the wrong place or for the wrong thing ... but I can't find anything regarding issuance or acceptance of emergency slow orders anywhere in the 18th edition of NORAC. Neither can I find any 'safety instructions' for Metro-North that don't refer to personal employee safety of more or less actionable kinds.
What is the precise Metro-North rule specifying the correct method of informing operating employees of critical slow orders related to track defects (rather than just trackwork or other maintenance-related zones)? And how is receipt of such an order supposed to be acknowledged, including the 'issuer's' reasonable assurance that the order has been communicated and received properly?
Not a Form D?
-Don (Random stuff, mostly about trains - what else? http://blerfblog.blogspot.com/)
BaltACDSo on Metro-North Slow Orders were a little deal. Got it.
243129 BaltACD Don't know Metro-North's procedures. The procedure was explained in an above post.
BaltACD Don't know Metro-North's procedures.
The procedure was explained in an above post.
So on Metro-North Slow Orders were a little deal. Got it.
Never too old to have a happy childhood!
BaltACDDon't know Metro-North's procedures.
Overmod charlie hebdo How were the speed restrictions communicated? They describe the procedure in the report. The problem, again, is in a paper system that is both inadequately communicated and inadequately back-checked for compliance. In 'the old days' on the New Haven, an emergency civil slow order for sun kink or other rapidly-developing track-geometry problem would probably have required the recipient to read it back word-for-word to 'show understanding' as well as confirm receipt. We could argue whether rote recitation is different from 'confirming the sense in one's own words', but in any case the order didn't make enough 'impression' on the engineer concerned to be memorable.
charlie hebdo How were the speed restrictions communicated?
They describe the procedure in the report.
The problem, again, is in a paper system that is both inadequately communicated and inadequately back-checked for compliance.
In 'the old days' on the New Haven, an emergency civil slow order for sun kink or other rapidly-developing track-geometry problem would probably have required the recipient to read it back word-for-word to 'show understanding' as well as confirm receipt. We could argue whether rote recitation is different from 'confirming the sense in one's own words', but in any case the order didn't make enough 'impression' on the engineer concerned to be memorable.
Don't know Metro-North's procedures.
On CSX when the Train Dispatcher issues a 'Mandatory Directive' (Slow Order, Stop & Flag, Track Warrant Authority or ANYTHING else that AFFECTS the operation of the train getting the Directive) the Directive must be repeated by the person getting the authority - the Dispatcher will compare what is repeated against the 'read back screeen' for the authority on his CADS computer - if not repeated correctly the Dispatcher will not 'activate' the authority and demand that the person repeat the authority again - UNTIL IT IS REPEATED CORRECTLY. Only then will the Dispatcher activate the authority in the CADS computer. The person copying and repeating the authority, by CSX Rules, cannot be at the controls of a moving train - the train must be stopped for the Engineer to handle the authority OR the Conductor must be brought to the operating Cab to copy and repeat the authority.
On CSX, if not on Metro-North, Slow Orders were a BIG DEAL.
charlie hebdoBoeing deliberately omitted any mention of the fatal, faulty system on the 737-Max from training manuals: profits and obscene compensation packages for executives over safety and human lives.
The Boeing Executives along with the Sackler family (Purdue Pharma) should be stripped of their riches and put in jail.
charlie hebdoHow were the speed restrictions communicated? By dispatchers?
This restriction was added to the Daily Train Operations Bulletin Order (DTOBO) as it was recently discovered. The engineer(s) did not follow protocol as is in evidence by his testimony.
"During the station stop, the engineer stated in his postaccident interview that he communicated with the RTC and received a Line C (speed restrictions received en route) to add to his Daily Train Operations Bulletin Order (DTOBO).15 The Line C information issued to the train engineer was for a speed restriction of 10 mph that extended from catenary pole 214 to catenary bridge 216, which are located between the Port Chester and Rye Train Stations. Metro-North Operating Rules (section 3, rule A, part 2) required the train engineer to communicate the Line C speed restriction to the train conductor. This action is to aid train engineers so that train conductors can remind them of approaching speed restrictions. The train engineer told investigators that he did not communicate the Line C speed restriction instructions to the train conductor."
Within the space of less than one hour this engineer(1373), also the previous engineer(1371), forgot a speed restriction with a reduction of 50 MPH in speed!?
My mantra no matter how annoying some may find it comes in to play here.
charlie hebdoHow were the speed restrictions communicated?
In 'the old days' on this specific part and perhaps this specific track of the New Haven, an emergency civil slow order for sun kink or other rapidly-developing track-geometry problem would probably have required the recipient to read it back word-for-word to 'show understanding' as well as confirm receipt. We could argue whether rote recitation is different from 'confirming the sense in one's own words', but in any case the order didn't make enough 'impression' on the engineer concerned to be memorable.
The fact that another train blew through the restriction a couple of hours earlier may be suggestive that the wording of the order didn't adequately confirm either the importance of the restriction or the specific nature of the problem as both evolving and severe. Perhaps the fact of it being a "10mph" slow order on a congested and very busy 70mph railroad at a significant traffic time was thought to be enough. I do have to wonder if there are so many lackadaisical readers on Metro-North's boards that ignorance lightning could strike twice for the same order.
I do note that the report is silent on what the reason for the earlier train's 'speeding' turned out to be. I'd be flat astounded that the Government boys weren't on that train number like hounds to the chase, and had that engineer in 'interviews' within hours...
How were the speed restrictions communicated? By dispatchers? Perhaps the system is faulty?
Two trains in a row 'blew' that speed restriction. Why?
charlie hebdo BaltACD Overmod charlie hebdo If he is non-compliant with his disease treatments, this should be examined more regularly as a policy . It's serious. I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment. It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance. I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance. The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens. I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.) Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons. If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'. If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only. The medical community expecting him to faithfully follow their recommendations is very naive. Ultimately, fitness for duty in civilian life depends on the company, not the doctor, medial or psychologist, unless we are employed by that company. Amtrak needs stricter procedures.
BaltACD Overmod charlie hebdo If he is non-compliant with his disease treatments, this should be examined more regularly as a policy . It's serious. I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment. It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance. I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance. The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens. I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.) Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons. If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'. If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only. The medical community expecting him to faithfully follow their recommendations is very naive.
Overmod charlie hebdo If he is non-compliant with his disease treatments, this should be examined more regularly as a policy . It's serious. I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment. It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance. I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance. The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens. I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.) Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons.
charlie hebdo If he is non-compliant with his disease treatments, this should be examined more regularly as a policy . It's serious.
I wonder if there is some HIPAA provision that would allow him to keep his 'lack of compliance' secret from his employer until oops! it turns out he wasn't taking critical meds or using critical equipment. It would also be somewhat hard, and probably invasive of some perception of medical privacy, to require some form of external oversight on the necessary basis (probably daily, and synchronized both home and 'away') that would "ensure" reasonably full compliance.
I do understand that 'examined more regularly' is not at all the same thing as enforcing dosing or administration compliance. The question is whether periodic regular examinations would catch the effects that are trying to be asserted here as an excuse, and I think they would not in either case ... unless imposed on a basis like that for random drug screens. I interpret the excuses as being (1) he was inattentive and forgetful because he didn't use his CPAP and was therefore 'tired' due to quality-of-sleep deprivation, and (2) he was inattentive and forgetful because of some kind of high blood sugar effect (low blood sugar not being a function of ignoring diabetes meds for the period given, unless I misunderstand current diabetes treatment modalities ... which is possible.) Neither of these is likely 'chronic' in ways that periodic checkups would necessarily reveal, although the effects are certainly very real at the time, and would be important to detect or determine for obvious reasons.
If the results of his non-compliance with his medical situation are as grave as are being represented the bigger question is 'Why was he permitted to operate on the regualr road jobs'. If the non-compliance with the recommended treatments is that severe, why wasn't he restricted to yard and/or hostler service only.
The medical community expecting him to faithfully follow their recommendations is very naive.
Ultimately, fitness for duty in civilian life depends on the company, not the doctor, medial or psychologist, unless we are employed by that company. Amtrak needs stricter procedures.
Company doctors examine employees fitness for duty, their decisions may be different than one's own personal doctor. Company doctors are the final authority.
ADHD (a major cause of inattention) is no longer diagnosed by physicians alone, though they prescribe meds if the diagnosis is made. They depend on a thorough neuropsych evaluation using a variety of tests. Unless FAA regs have changed, they do not permit pilots to use prescribed stimulant medication for ADHD. I'm not clear what the FRA position is.
This is from a website that pertains to commercial pilot training and licensing (not an official pilot-licensing site) :
"After the initial issue, you are required to attend a medical assessment on an annual basis until the age of forty, then every six months until the age of 65 which is the age at which class one medical privileges are revoked. Items such as ECG and audiograms are retested at periodic intervals, increasing in frequency with age." https://www.flightdeckfriend.com/become-an-airline-pilot/airline-pilot-medical-requirements/
"After the initial issue, you are required to attend a medical assessment on an annual basis until the age of forty, then every six months until the age of 65 which is the age at which class one medical privileges are revoked. Items such as ECG and audiograms are retested at periodic intervals, increasing in frequency with age."
https://www.flightdeckfriend.com/become-an-airline-pilot/airline-pilot-medical-requirements/
I know the age requirement for commericial pilots was changed from 60 to 65 not too many years ago.
York1 John
Overmod charlie hebdo Amtrak needs stricter procedures. This specific discussion is about Metro-North; it was a commuter train that 'went on the ground'. It's possible that Amtrak has stricter procedures to preclude this sort of thing -- but if they don't, your point does stand.
charlie hebdo Amtrak needs stricter procedures.
This specific discussion is about Metro-North; it was a commuter train that 'went on the ground'. It's possible that Amtrak has stricter procedures to preclude this sort of thing -- but if they don't, your point does stand.
Metro North and any railroad need systematic procedures to check on operating personnel with conditions that could impair their performance. They check on substances, but these factors are at least as important.
Track #3 should have been removed from service not speed restricted.
OvermodThird rail is the least of their factual problems;
One of their many factual problems.
OvermodI believe they attributed ownership on the east end, in Connecticut, to Metro-North,
The state of Connecticut owns from New Haven to the New York state line at Greenwich/Portchester.
Overmodand I think Amtrak now owns more of the west end than the NTSB said.
Amtrak territory begins from Chapel Street New Haven and east.
Overmodsloppy research and a certain cavalier attitude in both fact-finding and fact-checking.
Which is becoming more and more prevalent at NTSB.
charlie hebdoAmtrak needs stricter procedures.
As does Metro North.
Ultimately, fitness for duty in civilian life depends on the company, not the doctor, medical or psychologist, unless we are employed by that company. Amtrak needs stricter procedures.
243129I forgot to add 'poor supervision' to the title.
Well, go back and do it, then!
Third rail is the least of their factual problems; I believe they attributed ownership on the east end, in Connecticut, to Metro-North, and I think Amtrak now owns more of the west end than the NTSB said. This has little bearing on the actual 'controversy' addressed in the report, but it does show both sloppy research and a certain cavalier attitude in both fact-finding and fact-checking.
I forgot to add 'poor supervision' to the title.
This from NTSB report RAB1905: " The New Haven Line uses an electrified third rail between Grand Central Terminal and MP 14.9 in Pelham, New York."
The third rail territory ends east of Woodlawn interlocking and west of Mount Vernon station.
charlie hebdoIf he is non-compliant with his disease treatments, this should be examined more regularly as a policy . It's serious.
If he is non-compliant with his disease treatments, this should be examined more regularly as a policy. It's serious.
OvermodLink as formatted in the original post worked for me this afternoon. Like an idiot I did not save the downloaded PDF on this computer, and it disappeared just now when I tried to do so. It's a government server problem, and I expect it will be resolved when the government gets around to it. Link as provided will work when they do so. What happened was a developing case of sun kink on track 3 (the most northerly track of the 4) on the Metro-North part of the old New Haven. Several increasingly urgent calls about hard riding were checked, and increasingly rigorous slow orders issued. Apparently at least one MU then zipped through the area at track speed, then some fellow says he outright 'forgot' about the issued slow order and went right at it doing 56mph. He 'emergency braked' when he saw the kink, but put his train on the ground going over it. There is some mention in the report that this wasn't considered an 'accident', perhaps because nobody died. I'm not sure I'd concur about the importance. "Forgetting" a 10mph emergency slow order for progressive track kink could have been almost unbelievably deadly with a full load of passengers at 55mph. Usual excuses about sleep apnea, failure to use his CPAP, chronic diabetes but wouldn't take his meds, etc.
It's a government server problem, and I expect it will be resolved when the government gets around to it. Link as provided will work when they do so.
What happened was a developing case of sun kink on track 3 (the most northerly track of the 4) on the Metro-North part of the old New Haven. Several increasingly urgent calls about hard riding were checked, and increasingly rigorous slow orders issued. Apparently at least one MU then zipped through the area at track speed, then some fellow says he outright 'forgot' about the issued slow order and went right at it doing 56mph. He 'emergency braked' when he saw the kink, but put his train on the ground going over it.
There is some mention in the report that this wasn't considered an 'accident', perhaps because nobody died. I'm not sure I'd concur about the importance. "Forgetting" a 10mph emergency slow order for progressive track kink could have been almost unbelievably deadly with a full load of passengers at 55mph.
Usual excuses about sleep apnea, failure to use his CPAP, chronic diabetes but wouldn't take his meds, etc.
100% Man Failure - that the report is trying to blame on everything except the person's admitted failure.
I don't know Metro-North's procedures.
On my carrier - with a single person operating the 'locomotive'; when a inroute Train Message (Slow Order) is issued - the train must be stopped - person operating the 'locomotive' is prohibited from 'copying the mandatory directive' (Slow Order) while the train is in motion and the Engineer's attention needs to be focused on what he is doing in operating the train. From the report it is difficult to ascertain what procedures were used to communicate the Slow Order.
I can't determine the sense of 'urgency' that the Engineer attached to getting the slow order - in stating that he 'forgot' it; it is evident he attached no urgency to getting it and complying with it.
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