Passenger Trains > NTSB documents concerning Cayce, S.C. and Dupont Wash.wrecks

Pardon me if this has already been posted.

OPERATION AND HUMAN PERFORMANCE GROUP FACTUAL REPORT – CAYCE S.C.      
https://dms.ntsb.gov/public/61000-61499/61332/616694.pdf

Before reading, scroll through and find the maps.  That will make it much easier to follow the narrative.

From a former DS point of view the method of handling trains to the auto facility sure seems to be a
recipe for a cluster foxtrot.  Using the single main as a switching lead/yard track is like drilling a hole in
the bottom of the boat to let the water out.  That capacity constraining activity had nothing to do with the wreck. 

I have seen this type of nonsense many times.  The railroad doesn’t want to invest any money to keep
the main line clear because they will run the business off as soon as they have a chance.

Glad I am long retired.  My opinion is there is way too much fooling around with forms and jawboning on the radio
and too little emphasis on basic railroading.  Let’s worry about getting the switch lined back properly
and not worry about the stupid forms.  This accident shows how good the filling out of forms worked to prevent accidents.

For all the keyboard road foremen and trainmasters out there, it might be best if you let actual railroaders post
their comments on these incidents before giving us the benefit of your opinions.

TRAIN DISPATCHER VOICE TRANSCRIPTS – CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616725.pdf

INTERVIEW TRANSCRIPT-LOCOMOTIVE ENGINEER – CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616796.pdf

INTERVIEW TRANSCRIPT – CONDUCTOR – CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616800.pdf

INTERVIEW TRANSCRIPT – CONTRACTOR (EX-CHIEF DS) – CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616799.pdf

INTERVIEW TRANSCRIPT – TRAIN DISPATCHER –CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616794.pdf

INTERVIEW TRANSCRIPT  (SECOND INTERVIEW) – TRAIN DISPATCHER –CAYCE, S.C
https://dms.ntsb.gov/public/61000-61499/61332/616805.pdf

INTERVIEW TRANSCRIPT – ASSISTANT CHIEF DISPATCHER – CAYCE, S.C.
https://dms.ntsb.gov/public/61000-61499/61332/616795.pdf


WITNESS INTERVIEW TRANSCRIPT – DUPONT, WASHINGTON ENGINEER
https://dms.ntsb.gov/public/61000-61499/61332/616779.pdf

WITNESS INTERVIEW TRANSCRIPT – DUPONT, WASHINGTON     ROAD FOREMAN
https://dms.ntsb.gov/public/61000-61499/61332/616784.pdf

WITNESS INTERVIEW TRANSCRIPT – DUPONT, WASHINGTON     ROAD FOREMAN 2
https://dms.ntsb.gov/public/61000-61499/61332/616785.pdf

ONBOARD IMAGE RECORDER – DUPONT WASHINGTON
https://dms.ntsb.gov/public/61000-61499/61332/616896.pdf

SOUNDER EMPLOYEE TIMETABLE
https://dms.ntsb.gov/public/61000-61499/61332/616777.pdf


For the masochists in the audience who wish to read all of the mostly irrelevant documents the NTSB has posted so far:
https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=61332&StartRow=106&EndRow=120&CurrentPage=8&order=1&sort=0&TXTSEARCHT=

Question for you Amtrakers.  Is the current  DeCataldo the son of the guy who was a big wheel in the 1980’s ?
 

thanks for the posting!!!   some interesting insights into the training and issues.........Arlen

Reading the documents concering the Washington wreck I was reminded of something I had read about
a previous high speed, inagural voyage disaster, the Titanic.

The British Admirality investigation concluded that one of the causes was the increasingly northern route
the liners had been following over the previous years.  The ice pack had been receding (they did not mention
global warming) and icebergs had not been a problem as before.  A bad winter changed that.

Anyway the memorable statement from the Admiralty also applies in this case."Before the incident
no one would have given this route a second thought. Today,no one would even entertain the thought."
 

Englewood Wrote:
-------------------------------------------------------
> Reading the documents concering the Washington
> wreck I was reminded of something I had read
> about
> a previous high speed, inagural voyage disaster,
> the Titanic.


We don't often disagree, but I will here. This route shouldn't have been a problem. In the CREATE thread you started last night, dispr said: Who really cares what happened in the 60's or how the railroad operated then - those times are long lost to
history. To that, I responded that in itself is part of the problem. I also responded in another thread that there are 76 speed zones between Seattle and Portland and 69 speed zones between Seattle and Vancouver BC., many a 20 mph reduction, some a >=30 mph reduction. This is a new 20 miles on a 337 mile long line.

Now, let's look at the transcript:

Engineer:

In 2004, I hired on as a conductor, and I was hired as an engineer in 2013.

As an engineer, I've worked out of Portland. I've worked as far as Pasco to the east, Seattle to the north, and Klamath Falls to the south.

(As a conductor) worked out of Seattle and worked in Vancouver, BC. And I've worked as far east as Minot, because I worked out of Shelby temporarily, and, you know, south to Portland.

Now, everybody get their mind off of Deadman's Curve and training. From the cab recorder transcript:

6:17:22 ENG they’ve been changing so much, I still get lost sometimes down here if they send me down, like, main three down in, like, kelso or something [laughing]
6:17:34 QC what am I doing over here? [laughs]
6:17:37 ENG what do I do? what's the speed? I don’t know! [laughing]
6:17:51 ENG we stay on main one, and if that’s the case we don’t gotta worry about #
6:27:46 QC is that approach medium at orillia?
6:27:51 ENG uh, is this orillia? I think its orillia, I think its an intermediate
6:27:54 QC oh intermediate
6:27:55 ENG its an intermediate for us and its something over there. I think, uhh, its orillia over there? I get a little confused with the control points. what does your sheet say?
6:28:07 QC says its going to be orillia
6:28:11 ENG I think its orillia on those two tracks and then over here its intermediate
6:29:10 ENG this is orilia

This all occurred before they got to the beginning of the new line.

TAW
 

Very interesting the Amtrak engineer instead of plugging it went to handle off to try and get more braking. All that fancy in depth mechanical and air brake training in Wilmington and they don’t teach that you won’t get any extra braking effort past the point of equalization and the only option left is plugging it...not pissing your air away?
He did a lot more than spill some coffee....

Also found it interesting he was told not to use the footage counter because it’s a crutch.


Do the chargers keep blended braking when in emergency? I imagine they at least have DB holding to keep some dynamic brake effort?
Posted from iPhone



Edited 1 time(s). Last edit at 07/14/18 09:12 by jointauthority.

Reading this I'm wondering if the focus on training and experience might be displaced as well.

We've all ridden in cars with folks who have driven hundreds of thousands of miles but who get lost easily, brake for curves at the last minute, and occasionally blow through stop signs.  Unless the engineer was extremely sleepy or drugged that morning, I wouldn't be surprised to see transcripts of his past runs revealing a pattern of confusion and a tendency to become disoriented. 

Perhaps the failure is not so much with the training program, but in the inability (possibly accentuated by bureaucratic regulations) of trainers and supervisors to recognize and terminate/reassign someone who will have a higher-than-average risk of a disastrous rules violation. 

For all the downsides of PTC, it will at least leave a digital trail of overspeed violations for which PTC kicks in to compensate.


TAW Wrote:

> 6:17:34 QC what am I doing over here?
> 6:17:37 ENG what do I do? what's the speed? I
> don’t know!
> 6:17:51 ENG we stay on main one, and if that’s
> the case we don’t gotta worry about #
> 6:27:46 QC is that approach medium at orillia?
> 6:27:51 ENG uh, is this orillia? I think its
> orillia, I think its an intermediate
> 6:27:54 QC oh intermediate
> 6:27:55 ENG its an intermediate for us and its
> something over there. I think, uhh, its orillia
> over there? I get a little confused with the
> control points. what does your sheet say?
> 6:28:07 QC says its going to be orillia
> 6:28:11 ENG I think its orillia on those two
> tracks and then over here its intermediate
> 6:29:10 ENG this is orilia
>
> This all occurred before they got to the beginning
> of the new line.
>
> TAW
>  

Once PTC goes in, I would expect most engineers will probably keep the speed a little under the limit, precisely to compensate for the accidental over speed now and then. The BrightLine actual speeds often top out at around 76-77, at least on trips I've timed.  On a 79 mph limit

DeCataldo is one of the "families" that ran/run Amtrak.

Thank you 
for posting this. I read the entire Cayce accident transcripts. I agree with the previous posters, in that it is somewhat of a lack of training that caused both of these.

> All that fancy in depth mechanical and air brake training in Wilmington and they don't teach that you won't get any extra braking effort past the point of equalization and the only option left is plugging it...not pissing your air away?

Choo Choo U isn't big on explaining why and how air brake systems function, just rote memorization of factoids. One of the air brake instructors (now retired) had the unique ability to put bricks to sleep. When I would get students freshly back from Choo Choo U, I would quiz them about certain things, and they all told a common story: whenever they would ask for clarification on a point here or there, this guy would look at them with a deer in the headlights expression and then reread the text out of the book aloud. This is not "explanation".

For our "lay" readers: while "equalization", "equalizing reservoir", and "point of equalization" may all sound very similar, they refer to slightly different aspects of brake system functions.

"Equalization" is the the flow of air pressure between two or more volumes until the pressure in all is at the same value. The volumes can be the equalizing reservoir and brake pipe, the brake pipe and auxiliary reservoir, auxiliary reservoir and brake cylinder, the auxiliary reservoir and the emergency reservoir and the brake cylinder, and so on. Generally, "equalization" is used to refer to the brake pipe-auxiliary reservoir pressures, but you have to be sure to double-check the context of the discussion.

"Equalizing reservoir" is the reservoir attached to the chamber of one side of the equalizing piston. The EQ piston's function is to use the pressure in this chamber, which has been selected by the E using the automatic brake valve, to open or close the brake pipe discharge valve so that the BP pressure is equal to that of the EQ reservoir. The 26 system (26-L and 30CDW valves) have changed the name of this piston to "high capacity relay valve" because not only is it used to reduce BP pressure, it's also used to increase it and maintain the selected pressure against BP leakage.

"Point of equalization": while essentially the same as "equalization", this is most commonly used to discuss the point at which the auxiliary reservoir pressure is the same as the brake cylinder's. While usually spoken of in context of the situation after a full service brake application has been made (26 psi for a 90 psi brake pipe), if the brake system hadn't been fully charged before the application was made, it would be a random pressure less than what could be otherwise obtained.

These are the reasons why this sentence can be somewhat disorienting: "once you draw the equalizing reservoir down far enough, you reach the point of equalization, and further reductions of the equalizing reservoir won't produce increases in braking effort".

> Very interesting the Amtrak engineer instead of plugging it went to handle off to try and get more braking.

Under certain conditions, you can, but these aren't the norm. It's also gives unpredictable results because there are no ways to measure the pressures involved, so 9,999 times out of 10,000, it should never be attempted. Going into big hole activates quick action, which is designed to produce a brake cylinder pressure which is higher than full service, so it should always be used in this sort of situation (the Washington wreck).

> Also found it interesting he was told not to use the footage counter because it's a crutch.

Well, it is, and it's no more accurate than the speedo. So if the speedo is off by a few mph, as in reading 58 when you really going 61, which is well within CFR tolerances, you're going to get inaccurate footage readings. IOW, you're going to slow down too late. I used to tell my students to create a movie of the territory in their minds and insert landmarks for slowing down which aren't readily changeable or moveable (overpasses, buildings, small hills, etc.). Then when you go by one of these landmarks, gas 'em.

EtoinShrdlu Wrote:
-------------------------------------------------------
> > All that fancy in depth mechanical and air brake
> training in Wilmington and they don't teach that
> you won't get any extra braking effort past the
> point of equalization and the only option left is
> plugging it...not pissing your air away?

>
> For our "lay" readers: while "equalization",
> "equalizing reservoir", and "point of
> equalization" may all sound very similar, they
> refer to slightly different aspects of brake
> system functions.
>
> "Equalization" is the the flow of air pressure
> between two or more volumes until the pressure in
> all is at the same value. The volumes can be the
> equalizing reservoir and brake pipe, the brake
> pipe and auxiliary reservoir, auxiliary reservoir
> and brake cylinder, the auxiliary reservoir and
> the emergency reservoir and the brake cylinder,
> and so on. Generally, "equalization" is used to
> refer to the brake pipe-auxiliary reservoir
> pressures, but you have to be sure to double-check
> the context of the discussion.
>
> "Equalizing reservoir" is the reservoir attached
> to the chamber of one side of the equalizing
> piston. The EQ piston's function is to use the
> pressure in this chamber, which has been selected
> by the E using the automatic brake valve, to open
> or close the brake pipe discharge valve so that
> the BP pressure is equal to that of the EQ
> reservoir. The 26 system (26-L and 30CDW valves)
> have changed the name of this piston to "high
> capacity relay valve" because not only is it used
> to reduce BP pressure, it's also used to increase
> it and maintain the selected pressure against BP
> leakage.

>
> These are the reasons why this sentence can be
> somewhat disorienting: "once you draw the
> equalizing reservoir down far enough, you reach
> the point of equalization, and further reductions
> of the equalizing reservoir won't produce
> increases in braking effort".
>
> > Very interesting the Amtrak engineer instead of
> plugging it went to handle off to try and get more
> braking.
>
> Under certain conditions, you can, but these
> aren't the norm. It's also gives unpredictable
> results because there are no ways to measure the
> pressures involved, so 9,999 times out of 10,000,
> it should never be attempted. Going into big hole
> activates quick action, which is designed to
> produce a brake cylinder pressure which is higher
> than full service, so it should always be used in
> this sort of situation (the Washington wreck).

>
> Well, it is, and it's no more accurate than the
> speedo. So if the speedo is off by a few mph, as
> in reading 58 when you really going 61, which is
> well within CFR tolerances, you're going to get
> inaccurate footage readings. IOW, you're going to
> slow down too late. I used to tell my students to
> create a movie of the territory in their minds and
> insert landmarks for slowing down which aren't
> readily changeable or moveable (overpasses,
> buildings, small hills, etc.). Then when you go by
> one of these landmarks, gas 'em.

I agree that "over reducing" a brake pipe will do nothing constructive, and the damage it can do should be properly explained.  (Lack of a reliable emergengy application, and lack of higher emergency cylinder pressure.)

Nextly, "...removing the cable to keep the Charger from dieing when the dynamic brake was applied..." didn't even get mentioned again!  This problem would have been a low voltage ground somewhere in the cars or the rear P42, but by pulling the cable instead of fixing the problem (which would have taken time,)  they disabled the dynamic and the blended brake on the trailing unit!  The train should have been ready and tested much sooner! 

In this situation, full blended brake on the rear unit, instead of none, would only have given a couple of miles per hour of additional braking, but it would have been better than NONE!
G

but sometimes the air exhausting when in the overreduction zone sounds good.

"FAST Act", what is it?

Charlie

https://www.amtrak.com/content/dam/projects/dotcom/english/public/documents/corporate/reports/Amtrak-General-Legislative-Annual-Report-FY2019-Grant-Request.pdf

https://transportation.house.gov/uploadedfiles/highway_bill_conference.pdf
 
 

> I agree that "over reducing" a brake pipe will do nothing constructive, and the damage it can do should be properly explained. (Lack of a reliable emergengy application, and lack of higher emergency cylinder pressure.)

Once the brake pipe has been reduced below 50 psi, vent valves can't be relied upon to operate and cause quick action in the control valves (that emergency application). The U-6 and U-12 universal valves have protection valves which open below 50 psi, which ensures that the train can't be moved when the BP pressure is below 50 psi.

> In this situation, full blended brake on the rear unit, instead of none, would only have given a couple of miles per hour of additional braking,

Actually, it would have produced significant amount of braking.

> but sometimes the air exhausting when in the overreduction zone sounds good.

Perhaps, but it's misleading, dangerously so.

TAW Wrote:

>
>
> We don't often disagree, but I will 

No, we don't disagree.
I should have been more clear in my use of the quote about the Titanic.
I did not mean it be taken in reference to the railroad route but the qualification, training and supervision
of modern day engineers.

Who would think that someone would miss the one outstanding feature of a 20 mile route?
Especially on the first day when everyone is on their toes and after everyone has acknowledged the 
potential hazard.  As the Admiralty said "who would give it a second thought"?  Even the engineer 
does not know how he missed it.

As you have explained in other posts there is no other option to using the new route.


 



Edited 2 time(s). Last edit at 07/14/18 19:04 by Englewood.

EtoinShrdlu Wrote:
-------------------------------------------------------

> Choo Choo U isn't big on explaining why and how
> air brake systems function, just rote memorization
> of factoids. One of the air brake instructors (now
> retired) had the unique ability to put bricks to
> sleep. When I would get students freshly back from
> Choo Choo U, I would quiz them about certain
> things, and they all told a common story: whenever
> they would ask for clarification on a point here
> or there, this guy would look at them with a deer
> in the headlights expression and then reread the
> text out of the book aloud. This is not
> "explanation".
>

30, yes  t h i r t y,  years ago an Amtrak Divn. General Superintendent explained to me 
that a Rules Examiner DID NOT need extensive knowledge of the operating rules.
All that was needed were good presentation skills and the ability to follow the lesson
plan that HQ in Philly put out. BEAM ME UP !!!  It was at that moment that I began an exit plan 
from the company.  That is also when I came up with the line: "At Amtrak, rules have nothing to do
with Safety".  Here we are 30 years hence.

Ok I understand your point about that actually but being a freight guy the difference isn’t really going to matter unless your one of the guys who waits till the last possible second to bring it down.
It’s good to have a mental movie of the territory but it helps to use any tool available to you until you get enough footage to make your movie to play in your head. He definitely didn’t have enough mental footage yet.

“Well, it is, and it's no more accurate than the speedo. So if the speedo is off by a few mph, as in reading 58 when you really going 61, which is well within CFR tolerances, you're going to get inaccurate footage readings. IOW, you're going to slow down too late. I used to tell my students to create a movie of the territory in their minds and insert landmarks for slowing down which aren't readily changeable or moveable (overpasses, buildings, small hills, etc.). Then when you go by one of these landmarks, gas 'em.”

Posted from iPhone

Englewood Wrote:
-------------------------------------------------------
>  Even the
> engineer 
> does not know how he missed it.
 
Look at the part of the transcript I cited. He wasn't sure where he was when he left Tukwila and joked about being lost coming through Kalama, both of which are on the route he has been running for years. Yeah, they added track and signals...as he was running through there over the past four years. Orillia over there? He was on Main 1. The Orillia plant is on Main 2 and 3. The Tukwila station he just left is on 1 & 3...and he wasn't sure about over there? So where else was he lost or confused? The video shoes the clues IO have been citing all along. I would hope that no rail posting here would miss clues like that even on the first trip over the road.

Scarier yet, he jokes and laughs about being lost out there.

TAW

jointauthority Wrote:
-------------------------------------------------------

> I used to tell my students to
> create a movie of the territory in their minds and
> insert landmarks for slowing down which aren't
> readily changeable or moveable (overpasses,
> buildings, small hills, etc.). Then when you go by
> one of these landmarks, gas 'em.”

Yes. This is why I have been saying for a long time that training is so bad in the industry that folks aren't taught how to learn the road. I've noticed this with train dispatchers years ago. This guy was apparently trying to identify where he was at by looking for the small (BNSF standard mileposts are hard to see, I'll give him that) milepost sign for 18 instead of a big bridge, a curve, another bridge...and the signal that was shining right down the center of the track because it was in the curve a little. I learned to learn the road on my very first trip on an engine The conductor in the cab learning the road was in the same boat - missing the big permanent clues that anyone with more seniority than vacation should never miss.

TAW