Philadelphia Amtrak Crash

[jjb1970]

I'm not saying that Amtrak do not want to know what happened, I'm saying that from a public relations and legal liability perspective and generally from a natural corporate response to incident perspective it would be much more preferable for them if they could point at a rogue driver ignoring regulations rather than having to have their equipment, staff training, staff rostering and safety management system in general under the spotlight in an incident like this. Maybe I'm jaundiced by experience but I'm pretty much at a point where I see two attitudes in companies nowadays. The first, admirable attitude is that of internal investigators, operations and engineering specialists etc who are committed to finding out what happened so as to amend equipment and systems so as to avoid a repeat. The second is a corporate attitude which now seems to be find someone we can blame that isn't us.

[Andy Reichert]

I'm not saying that Amtrak do not want to know what happened, I'm saying that from a public relations and legal liability perspective and generally from a natural corporate response to incident perspective it would be much more preferable for them if they could point at a rogue driver ignoring regulations rather than having to have their equipment, staff training, staff rostering and safety management system in general under the spotlight in an incident like this. Maybe I'm jaundiced by experience but I'm pretty much at a point where I see two attitudes in companies nowadays. The first, admirable attitude is that of internal investigators, operations and engineering specialists etc who are committed to finding out what happened so as to amend equipment and systems so as to avoid a repeat. The second is a corporate attitude which now seems to be find someone we can blame that isn't us.

 

But that is stereotyping.

 

Andy

[jjb1970]

I'll admit it is stereotyping and making a sweeping generalisation, however after a while it is hard to avoid this sort of stereotyping I find. I work for a risk management organisation and am routinely seconded to various state agencies in a range of countries to assist with incident investigations and provide technical analysis of machinery failures (not in rail I hasten to add) and I have to say that the statement accurately reflects my personal experiences.

[dave1905]

Part of the problem that people seem to overlook is they are also trying to coordinate the TRAIN operation and the SIGNAL operation and the CELL phone operation.  All of which that may have clocks and various other measuring systems that do not run off a coordinated UTC.  Its really neat that some companies have that but there are companies that have legacy technology that was originally designed in the 1930's.  I have had to work through some of these types of issues before.  The engine is on one clock, the signal system on another and the information system on a third.  The difference between them is typically less than 30 sec apart, but in things legal that is a big deal.

[dibber25]

Do journos ever make that effort?

 

Cheers,

 

Mark.

Don't tar us all with the same brush, please. There are many thousands of specialist, technical journalists who put in a great deal of effort. What was clear from US TV news coverage at the time was that a different 'reason' was being put forward every day and being picked up by the non-technical media. You can't blame non-technical journalists if they are fed snippets about shot-out windshields, thrown stones, concrete falling off bridges or staff using mobile phones. The technical folk know that they - and the rest of us - must wait until the NTSB report is published.

CHRIS LEIGH

[dibber25]

Chris is spot on.

 

Would be nice to think that everyone else on here will now wait until the report comes out.

When I worked at IA, we used to get the NTSB reports sent to us when they were published. Like the reports done by HMRI in the past, they always made fascinating reading. On one occasion Mike Harris asked me to write a feature for 'Modern Transport' looking at three or four hazchem accidents in the USA. I thought the reports were quite remarkable for their thoroughness and they proved that on many occasions accidents are just that - accidents, and it is difficult to find any individual or organisation to blame. In one accident a car had picked up epoxy resin on its wheels from spillage in a private siding. It then went through the retarders in a hump yard (in Texas, I think) and spread epoxy on the retarders with the result that subsequent cars were not slowed down. One car ran down into a stationary tank car containing ( I think) LPG, which blew up. An aerial view showed rows of cars lying on their sides from the blast.

In another accident, car drivers had died when they got out of their cars to check why their engine had stalled. They were used to thick fogs in the area but on this occasion the 'fog' was a deadly gas leaking from a derailed tank car, which had starved the cars and then the drivers, of air. 

The skill and diligence in finding the answers is admirable but there are always those where the only people who know exactly what happened and why, are dead, and those where what the HMRI called 'misguided loyalty' led staff to try to cover for the mistakes of their colleagues.

CHRIS LEIGH

[jjb1970]

The biggest advance (in my opinion) seen in accident investigation in recent decades has been the move away from a concentration on the immediate causes and failings of incidents (noting that most investigations tend to be into events which did not escalate to actual disasters and fatal injuries) to take a much wider view including human behaviours, corporate cultures and ergonomics. Most incidents have immediate causes and underlying causes and it is now recognised that the sort of underlying causes that were often overlooked in the past are critical to improving safety. Certainly nowadays reports which just offer an explanation of human error to explain an incident would have to provide some rationale to support this assertion to be taken seriously as whilst human error may be at play it then raises questions about training, authorisation/passing out, management over sight, working practices, management culture, ergonomics, system susceptibility to maloperation etc etc. In the past human error was often offered as the only cause needed in incidents. Equally, nowadays if you list machinery failure it raises questions about quality control during manufacture, design verification etc etc and is not just a simple explanation.

[Jeff Smith]

Human Factors is the current term for studying and learning from incidents/accidents that involve human decisions. This is routinely covered by courses in most manufacturing, maintenance and transport industries nowadays.

 

An example of how difficult investigations can be to get to route cause was the Airbus A300 that crashed shortly after take off from JFK in 2001. The fin broke off and the aircraft crashed on housing. Lots of testing was done to see how strong the composite fin was and the structure was shown to exceed design requirements. Attention then turned to wake turbulence however separation from the aircraft ahead was within allowable limits. The turbulence was commented on by the captain to the first officer, who was in control, who responded that he could handle it. Shortly after, the fin detached due to extreme side to side rudder movement which overstressed the fin structure. It turned out that the airline simulator training was instructing pilots to do these rapid extreme corrections when in wake turbulence. So in fact it was only a matter of time until an accident occurred.

[jjb1970]

The Airbus A300 incident displayed another interesting characteristic of incidents in that there was a very vocal body of opinion that blamed the crash on a failure of the composite fin as a result of the material not being suitable for the application and by extension holding Airbus to be responsible. At the time the use of composites in airliners was seized upon by parts of the media as being untried or unsafe and the alleged composite failure provided a reason for the crash that ticked the right boxes for a few observers and commentators. No matter how much analysis was provided to demonstrate that the immediate cause of the crash was inappropriate control inputs by the pilots there was a significant body that was determined to hold onto the idea that it was some nefarious use of composites by Airbus that was to blame and indeed increasing efforts to disprove that assertion were seen by many as actually providing more reasons to believe it. In that way it had similarities with the loss of the Derbyshire. Some of a certain age will recall just what a controversial subject the Derbyshire was and that there was a very vocal campaign to hold British Shipbuilders responsible for the hull breaking apart as a result of a discontinuity in a hull member and that it was all hushed up in a government conspiracy. Despite being debunked and despite the face of a mountain of analysis and evidence (not least the discovery of the wreck) there are still people who refuse to accept that the conspiracy theory was false.

[Jeff Smith]

Yes, Boeing at the time was a staunchly aluminium aircraft constructor but now builds the 787 largely from composite materials.....

[Colin_McLeod]

Why let the facts spoil a good conspiracy story. LOL

[Talltim]

Human Factors is the current term for studying and learning from incidents/accidents that involve human decisions. This is routinely covered by courses in most manufacturing, maintenance and transport industries nowadays.

 

An example of how difficult investigations can be to get to route cause was the Airbus A300 that crashed shortly after take off from JFK in 2001. The fin broke off and the aircraft crashed on housing. Lots of testing was done to see how strong the composite fin was and the structure was shown to exceed design requirements. Attention then turned to wake turbulence however separation from the aircraft ahead was within allowable limits. The turbulence was commented on by the captain to the first officer, who was in control, who responded that he could handle it. Shortly after, the fin detached due to extreme side to side rudder movement which overstressed the fin structure. It turned out that the airline simulator training was instructing pilots to do these rapid extreme corrections when in wake turbulence. So in fact it was only a matter of time until an accident occurred.

Surely that just shows that the design requirements for the fin were wrong?

[jjb1970]

Surely that just shows that the design requirements for the fin were wrong?

Indeed, however if that point is made it was equally applicable to other aircraft. At the time it was presented as being a particular failure of an Airbus composite fin yet subsequent analysis showed that the forces acting on it would have ripped off the fin regardless of materials. Ultimately there are limiting factors to any design beyond which they will fail. What those limits should be tends to be a dynamic argument as it changes over time but in this particular case there was a rather unpleasant undertone in that an opportunity was spotted to present Airbus as selling unsafe aircraft when in fact if an aircraft was unsafe if the fin could not stand the forces this particular one was subjected to then all other airliners were unsafe too.

[Jeff Smith]

Well argued.  In fact procedural problems are quite often the route cause of incidents, and in their worst manifestations accidents.  Dynamic systems such as railways, aircraft, etc all have limitations the secret is to understand them and try to ensure they are not exceeded......static systems too of course, Tay bridge comes to mind but that was a design fault!

[Grovenor]

 

Tay bridge comes to mind but that was a design fault!

Indeed, but not a simple designer's mistake. It related to the wind speeds the designer was advised to allow for and hence the underlying management systems.

Anyway, without that disaster we would never have had the Forth bridge in its present magnificent form, so some good came of it.

Regards

Keith

[Jeff Smith]

Indeed, but not a simple designer's mistake. It related to the wind speeds the designer was advised to allow for and hence the underlying management systems.

Anyway, without that disaster we would never have had the Forth bridge in its present magnificent form, so some good came of it.

Regards

Keith

I thought the popular notion was that the bridge structure was designed to take the highest expected wind pressure but the additional wind resistance of a train was not allowed for.......

[Edwin_m]

The maintenance of the Tay Bridge was also significantly at fault. 

[LNER4479]

...as was its construction!

 

('poorly designed, poorly constructed and poorly maintained' - conclusion of the official inquiry. In engineering terms: a full house)

[Talltim]

It's a called a conversation, they wander.

[The Stationmaster]

But has nothing to do with the Amtrak crash gents!

True - but at present, pending anything from the NTSB, there is nothing to be added in respect of that incident so the conversation is following related lines in respect of things such as incident investigation and causation.

[LNER4479]

[Andy Reichert]

Re: some previous discussion on not quickly getting cell phone records.

 

http://www.npr.org/sections/thetwo-way/2015/08/05/429811491/cell-phone-service-down-for-thousands-but-regulators-may-never-know-why

 

I'm stuck with AT&T where I am located. From my many experiences, they have to be one of both the greediest and the worst service providing companies in the world.

 

Andy

[jamie92208]

The latest issue of Trains Magazine has a very good piece by Don Phillips about the crash.  He has been given some deep background by the Transportation Safety Board.  Apparently their staff are very impressed with the driver but he at the moment he has no memory of the crash.  It's well worth a read.

 

Jamie

[Talltim]

The NTSB report is now out http://www.ntsb.gov/investigations/AccidentReports/Reports/RAR1602.pdf

[The Stationmaster]

Only had a skim but a nice sensible Report and a good example of how to tackle such a task.  The Conclusions in particular are very well set out and in nice clear language and no wandering off into a load of references to documents - just states the concluded situation.

 

(I won't say who should be reading this Report to see how it should be done)