Passenger Trains > PHL Inquirer: Feds confirm Amtrak failed to follow safety rules

Feds confirm Amtrak failed to follow safety rules in fatal train crash
Philadelphia Inquirer
January 8, 2016
by Jason Laughlin

> A federal directive issued to Amtrak Wednesday night confirms the
> rail agency's workers weren't following basic safety rules when a
> weekend train crash killed two people in Chester.
>
> The directive of action from the Federal Railroad Administration is
> the first official confirmation that safety rules weren't followed in
> the Sunday crash. Specifically, it highlighted concerns about the
> way personnel working on tracks follow safety standards. It stated
> both federal regulations and Amtrak's internal rules were not being
> followed at the time of the crash, according to information provided
> by a senior FRA official.
>
> Sources with knowledge of the crash near Booth Street have said a
> communications lapse between changing shifts contributed to the
> crash. Two veteran Amtrak workers in or near a backhoe directly in
> the path of an oncoming train were killed. Multiple federal and
> agency rules and regulations are designed to prevent trains from
> traveling on tracks occupied by workers and their vehicles.
>
> The FRA ordered Amtrak late Wednesday night to require all railroad
> maintenance workers and their supervisors to review safety rules
> applicable to their jobs. The regulatory agency also required Amtrak
> to review the rules governing communication between rail workers,
> their foremen and dispatchers. FRA also recommended that the rail
> agency conduct a similar safety review for all safety sensitive
> workers.
>
> In the case of rail incidents, the FRA conducts its own investigation
> parallel to one underway from the National Transportation Safety
> Board. The FRA issued the directive because of information received
> during its investigation, which is ongoing.

LINK:

Feds confirm Amtrak failed to follow safety rules

As in the deadly Train 188 crash, the FRA has issued a directive ordering Amtrak to comply.  

"We have a strong safety record."  -Joe Boardman



Edited 1 time(s). Last edit at 04/07/16 08:32 by GenePoon.

---

Another good article on Amtrak's policies about shunting tracks.

http://www.philly.com/philly/blogs/in-transit/Amtrak-train-crash-mirrors.html

Hard to believe it is or was a controversy that a track occupied by MOW should be shunted to ensure the ATC prevents entry of misrouted trains!

Amazing too that this is really the same problem at Frankford Jct. - not using the existing capabilities of the 60 year old signal technology and its automatic braking features to protect workers, passengers, and railroad capital equipment.

Forget PTC.  Every mention of it in an article is an infuriating red herring here.  The existing ATC system with its nine speed codes is fully capable of being used to protect all restricting curves just like it protects restricting turnouts, and of being used to forbid entry into tracks out of service or fouled.  The only reason given for not using it this way is money (i.e new code change point equipment would need to be installed at restricting curves, and work crews would need to have and use shunting cables and take the time to put them on).  Apparently periodic catatrophes are considered to be cheaper than using the fail safe signal system already in place.  Just a completely mind boggling attitude.

http://www.wsj.com/articles/federal-railroad-administration-calls-for-immediate-amtrak-safety-reviews-1460000996

Wall Street Journal is now confirming that the foul time was given up by cell phone call.

Amtrak Mid Atlantic Division Dispatchers Manual reads:

"1.14 Cell Phones - The use of personal cellular telephones for the conduct of company business is prohibited. Cell phones may only be used for the purpose in the event of a failure of all other means of communication. Employees who must resort to their personal cell phones will upon submission of proper documentation, be reimbursed for their expenses.
"With regard to the use of cellular telephones by M/W foreman and other employees requesting foul time or form Ds, such employees must be directed to utilize the radio, except in the event that their particular location precludes radio transmission or reception."

I've worked on Amtrak's tracks in Chester with the MOW gangs under foul protection in 1996 on a nearly identical task as the one which got the two workers killed.  I rather doubt that Chester is a radio dead zone because we used company radios there at that time in the days before cell phones, and I also doubt that the foreman who gave up track authority even bothered to try to use a company radio.  I also doubt the dispatcher directed him to utilize the radio for the request.  I am willing to bet that using cell phones to obtain and give up track authority was being done all the time, and that radios were rarely being used to do so.  It is easy to slip into comfortable bad habits.

I have worked on a transit property in the past where it was procedure to call into the dispatcher to obtain track occupancy for certain activities.  In these cases, the dispatcher would grant authority and would repeat over the radio to all train operators and others on the channel that track workers were going to be present at a certain location working under individual train detection or minimal flag protection.  We would also give up authority via cell phone, and identical statements would be made by the dispatcher that track workers had now left the area and no longer needed to be watched for by crews.  We had to use individual identification numbers to the dispatcher to confirm we had permission to make these requests.  I kind of doubt that Amtrak's dispatchers are in the habit of doing radio repeats with requests via cell phone from MOW foreman.

Hopefully all of this is going to change for the better and safer soon!



Edited 1 time(s). Last edit at 04/07/16 09:01 by abyler.

Even in a case where a cell phone is permitted, there are severe restrictions on the use.

Cowboys.

Could thoroughly banning cell phone possession by MofW crews on duty be an outcome ?



Edited 1 time(s). Last edit at 04/07/16 09:29 by joemvcnj.

Things flow down from the top. Things rarely move up from the bottom. So true with safety!

White-collar crime definition: white-collar crime refers to financially motivated nonviolent crime committed by business and government professionals. Within criminology, it was first defined by sociologist Edwin Sutherland in 1939 as "a crime committed by a person of respectability and high social status in the course of his occupation".

abyler Wrote:
-------------------------------------------------------
> http://www.wsj.com/articles/federal-railroad-admin
> istration-calls-for-immediate-amtrak-safety-review
> s-1460000996


Wall Street Journal is now confirming that the foul time was given up by cell phone call.


What do you mean by given up?

elu34ch Wrote:
-------------------------------------------------------
> abyler Wrote:
> --------------------------------------------------
> -----
> >
> http://www.wsj.com/articles/federal-railroad-admin
>
> >
> istration-calls-for-immediate-amtrak-safety-review
>
> > s-1460000996
>
>
> Wall Street Journal is now confirming that
> the foul time was given up by cell phone call.
>
>
> What do you mean by given up?

Released. 

So, the TA (or in this case foul time) was 'given up' or released. 

glendale Wrote:
-------------------------------------------------------
> elu34ch Wrote:
> --------------------------------------------------
> -----
> > abyler Wrote:
> >
> --------------------------------------------------
>
> > -----
> > >
> >
> http://www.wsj.com/articles/federal-railroad-admin
>
> >
> > >
> >
> istration-calls-for-immediate-amtrak-safety-review
>
> >
> > > s-1460000996
> >
> >
> > Wall Street Journal is now confirming that
> > the foul time was given up by cell phone call.
> >
> >
> > What do you mean by given up?
>
> Released. 
>
> So, the TA (or in this case foul time) was 'given
> up' or released. 

...as in  We're not using the track any more.

TAW

abyler Wrote:
-------------------------------------------------------
> http://www.wsj.com/articles/federal-railroad-admin
> istration-calls-for-immediate-amtrak-safety-review
> s-1460000996
>
> Wall Street Journal is now confirming that the
> foul time was given up by cell phone call.

===================================================

Finally, to the crux of the matter (yes, Andy and I knew about it...as did OOS which is part of what infuriated him so
much...his co-workers, and friends for decades, died because of a critical error in procedure).

The foul was given up by cellphone call (reports say the employee wasn't even on the property or in a company
vehicle at the time).  This should not be done for a good reason: SO THAT THE EMPLOYEES ON THE GROUND KNOW IT IS 
BEING RELEASED and that THOSE IN FOUL ARE NO LONGER PROTECTED.

By doing it on a cellphone, the employee set things up so that the employees in the backhoe and on the ground nearby,
and the Loram crew, and the new crew just coming on duty including the foreman did NOT know the foul had been
released.  They did NOT know they were no longer protected.  They did NOT know that the dispatcher, now with the
foul released, could clear Train 89(3) onto that same track...and did just that.

We must consider whether the dispatcher, having received release of the foul improperly via phone, was also obligated
to NOT accept it in such a manner that the men on the ground could not have heard it.  If the rules prohibit accepting the
release by cellphone, the dispatcher is also culpable.   The rule does appear to apply to the dispatcher:

> ...such employees must be directed to utilize the radio, except in
> the event that their particular location precludes radio transmission
> or reception."

I suppose if the employee were in his car driving home, he might be in such a location...but is that
where he was supposed to be while performing a critical safety function?

Regardless...he is an Amtrak employee, did not follow the rule, and another Amtrak employee did not
catch him on it and/or correct the condition. Two good railroad men are dead...and one seriously
injured.

 



Edited 7 time(s). Last edit at 04/07/16 10:21 by GenePoon.

---

TAW Wrote:
-------------------------------------------------------
> glendale Wrote:
> --------------------------------------------------
> > elu34ch Wrote:
> --------------------------------------------------
> > > abyler Wrote:
> > >
> > > Wall Street Journal is now confirming that
> > > the foul time was given up by cell phone
> call.
> > >
> > >
> > > What do you mean by given up?
> >
> > Released. 
> >
> > So, the TA (or in this case foul time) was
> 'given
> > up' or released. 
>
> ...as in  We're not using the track any more.
>
> TAW

As in: "Hey, CTEC?  Yeah, this is Joe Blow.  We are off Track 3 and everyone is in the clear.  Phil Schmoe will call up in a bit to get the track back.  Yes, you can run train 89 through our worksite now.  We are off Track 3."

Or words to that effect that were actually not true because the person speaking them was not even physically on site.

abyler Wrote:
-------------------------------------------------------

> Or words to that effect that were actually not
> true because the person speaking them was not even
> physically on site.

It appears that he did not even give the new-shift employee replacing him a briefing.  Just left the worksite.

My understanding is that when the relieved foreman released the track his crew was clear of all tracks. This occured shortly after a shift change and a new crew, in addition to the foreman, coming on duty.

abyler Wrote:
-------------------------------------------------------
> TAW Wrote:
> --------------------------------------------------
> -----
> > glendale Wrote:
> >
> --------------------------------------------------
>
> > > elu34ch Wrote:
> >
> --------------------------------------------------
>
> > > > abyler Wrote:
> > > >
> > > > Wall Street Journal is now confirming that
> > > > the foul time was given up by cell phone
> > call.
> > > >
> > > >
> > > > What do you mean by given up?
> > >
> > > Released. 
> > >
> > > So, the TA (or in this case foul time) was
> > 'given
> > > up' or released. 
> >
> > ...as in  We're not using the track any more.
> >
> > TAW
>
> As in: "Hey, CTEC?  Yeah, this is Joe Blow.  We
> are off Track 3 and everyone is in the clear.
>  Phil Schmoe will call up in a bit to get the
> track back.  Yes, you can run train 89 through
> our worksite now.  We are off Track 3."
>
> Or words to that effect that were actually not
> true because the person speaking them was not even
> physically on site.

Yup, it's coming together just as I thought it might.

Everything should be in writing, and the written material should be shared with the people it protects (personally to the extent practicable or verbally) and transferred to the next shift. No paper, no track.

TAW

reindeerflame Wrote:
-------------------------------------------------------
> Cowboys.


Eagles far more likely.

GenePoon Wrote:
-------------------------------------------------------
> abyler Wrote:
> --------------------------------------------------
> -----
> >
> http://www.wsj.com/articles/federal-railroad-admin
>
> >
> istration-calls-for-immediate-amtrak-safety-review
>
> > s-1460000996
> >
> > Wall Street Journal is now confirming that the
> > foul time was given up by cell phone call.
>
> ==================================================
> =
>
> Finally, to the crux of the matter (yes, Andy and
> I knew about it...as did OOS which is part of what
> infuriated him so
> much...his co-workers, and friends for decades,
> died because of a critical error in procedure).
>
> The foul was given up by cellphone call (reports
> say the employee wasn't even on the property or in
> a company
> vehicle at the time).  This should not be done
> for a good reason: SO THAT THE EMPLOYEES ON THE
> GROUND KNOW IT IS 
> BEING RELEASED and that THOSE IN FOUL ARE NO
> LONGER PROTECTED.
>
> By doing it on a cellphone, the employee set
> things up so that the employees in the backhoe and
> on the ground nearby,
> and the Loram crew, and the new crew just coming
> on duty including the foreman did NOT know the
> foul had been
> released.  They did NOT know they were no longer
> protected.  They did NOT know that the
> dispatcher, now with the
> foul released, could clear Train 89(3) onto that
> same track...and did just that.
>
> We must consider whether the dispatcher, having
> received release of the foul improperly via phone,
> was also obligated
> to NOT accept it in such a manner that the men on
> the ground could not have heard it.  If the rules
> prohibit accepting the
> release by cellphone, the dispatcher is also
> culpable.   The rule does appear to apply to the
> dispatcher:
>
> > ...such employees must be directed to utilize
> the radio, except in
> > the event that their particular location
> precludes radio transmission
> > or reception."
>
> I suppose if the employee were in his car driving
> home, he might be in such a location...but is
> that
> where he was supposed to be while performing a
> critical safety function?
>
> Regardless...he is an Amtrak employee, did not
> follow the rule, and another Amtrak employee did
> not
> catch him on it and/or correct the condition. Two
> good railroad men are dead...and one seriously
> injured.
>
>  
It's a fairly standard safety principle that one should never make assumptions about having someone else having established forms of protection.  It's called failing safe.  If the second shift didn't get their safety briefing they should have positivly assertained what their authorities were instead of just assuming things were still ok.

Phones, cell or Amtrak lineside, are used to avoid tying up the radio channel used by the train crews and because it gets the dispatcher's attention sooner. 

I have heard on the radio a train crew coming on duty checking with the dispatcher in a formal(proscribed I would assume) manner that a warrant is still in effect.
I am not sure what the rules are but seems if you come on duty, track crew included and the old crew is no longer around and equipment is parked you need to talk to the dispatcher to confirm the status of the track???  I know that makes some asumptions but just following what seems to be the scenario people are arriving at?

Bob
 



Edited 1 time(s). Last edit at 04/07/16 11:57 by robj.

I understand rules are rules, but I think strictly using the radio for all communication is outdated. I work for a Class 1 railroad and use a laptop computer to obtain track authority silently. My only direct communication to the DS is just a briefing of my plan. That can be over the radio, a phone call or an instant message using the track authority software. It is my responsibility to then share the track authority with my workgroup.



Edited 1 time(s). Last edit at 04/07/16 12:11 by MP555.

TAW is correct (as usual.)  Written transfers between dispatchers on shift change are a mandatory act.  The form in which they are written has changed, being done by computer today, but there is still a copy available.  One of the reasons for this is to protect the parties involved.  No "he said, she said" kind of thing.  Having to put the transfer to paper or computer also makes the party doing the transfer think more about what he has to inform his relief, cutting down on the chances that he might forget something.  Doing it verbally, especially on site where it is probably loud, noisy, and distracting, is not the best scenario.  If MOW forces did a transfer this way, they would not have the opportunity to "cut corners" either; the transfer would have to be available for anyone to see.  I suspected that miss-communication was the underlying cause to this tragedy.  But the talk about not using shunts regularly plays into this.  If shunts were used as instructed, the foreman coming on duty would see that the shunts were applied or not, and would then know enough to question whether the track authority was or was not in effect.

TWA Wrote:
-------------------------------------------------------
>
> Yup, it's coming together just as I thought it
> might.
>
> Everything should be in writing, and the written
> material should be shared with the people it
> protects (personally to the extent practicable or
> verbally) and transferred to the next shift. No
> paper, no track.
>
> TWA