After two and one-half hours of presentations, questions, comments, and answers, all streamed live to tablets, laptops, desktops, phones, the NTSB unamimously adopted 19 findings (causes) for five separate accidents that occurred on Metro-North Railroad between May 2013 and March 2014.
Based on the 19 findings, NTSB unanimously adopted 17 new recommendations; reissued 9 previous recommendations; and reclassified 3 recommendations.
Unlike the operatic performance conducted on October 28 by the NTSB, with words and lyrics by the team of Schumer and Blumenthal, where the main character "The Schumenthal" valkyried across the stage, swords slicing the air in search of heads, this NTSB meeting was delivered without drama and or farce (mostly, and mostly's about as good as it gets for government work).
Played straight, the NTSB review appears moderate, modest and well-reasoned. And appearance, presentation, is mostly everything when we're streaming. Mostly.
The presentation mostly eviscerates FRA's claims to the responsible regulation of railroads in the interest of public safety. The presentation mostly demolishes Metro-North's claims to safety as a first priority. Mostly.
All of NTSB's findings are crystal clear, mostly, but ALL of that clarity comes from the visual acuity associated with hindsight. And hindsight, because it serves the agenda of the viewer, has its own blindspots-- glaring blindspots, you should pardon the oxymoron.
So what's NTSB's agenda, or agendas? Why, it's "safety culture," of course, and not just any safety culture, but only a just safety culture.
Now far be it from me to impugn the importance of a safety culture. However, the basis of any safety culture is the individual acknowledgement and proper discharge of responsibility. Failure to acknowledge and properly discharge responsibility is a vital threat to safe train operations.
NTSB, advancing its agenda of a just safety culture, concludes that the locomotive engineer who caused the derailment of train 8808 failed to control the speed of the train properly due to chronic obstructive sleep apnea.
There is no proof that sleep apnea caused this derailment. The issue of "dozing off" was first raised by the locomotive engineer's union representative shortly after the occurrence.
Later tests determined that the employee had suffered from sleep apnea. No tests can determine if the employee had fallen asleep at the time of the accident. According to reports published immediately after the accident the employee reported that the brakes had failed.
Now however, NTSB has concluded, and you can be sure these conclusions will be part of every lawyer's brief filing for damages, that indeed the employee is not responsible. MNR is responsible because it had/has a defective and unjust safety culture. MNR is responsible because it expected and required locomotive engineers to operate train to schedule. And FRA is responsible for not implementing prior NTSB recommendations.
Hell, if I were that locomotive engineer's lawyer, I'd be preparing my client's own lawsuit against Metro-North Railroad for damages due to its failure to screen him for sleep apnea; and for the "pressure" it placed on him to satisfy train schedules. I know I'd win that case, hands down. All I'd have to do is hand the jury this NTSB report, and FRA's Deep Dive report.
I bring this up because 1)when we turn in a cause for an accident, we have to have conclusive evidence otherwise we are contaminating the investigation process 2) a close friend and colleague noted a mystery of mysteries: NTSB makes NO recommendation, not a single one, to railroads or FRA regarding the timely installation of Positive Train Control (once upon a time the "go-to" fall-back recommendation for criticizing FRA "inaction").
Nor does NTSB recommend the augmentation of automatic train control systems to enforce, automatically, permanent "civil" speed restrictions on curves, bridges, etc.
Those of you familiar with a bit of history will recall that back in 2005 NTSB recommended that Metra install automatic speed control to protect against exceeding signal mandated speeds at interlockings.....and that Metra said something like "We'd love to, but what's the point? We're going to install ETMS, a far more complete train control system." Of course, Metra has not installed ETMS yet, but NTSB apparently doesn't see the MNR accidents as an opportunity to reiterate that recommendation, although incidents of overspeeding on Metra have precipitated another FRA investigation.
Instead we get findings and recommendations regarding the installation of permanent speed signs, inward and outward facing cameras, medical standards, risk management-- all part of a robust, and just, safety culture I'm sure, but none of which do a thing to automatically enforce compliance and prevent overspeeding.
I'd like to ask the NTSB why is that? Why the absence of recommendations regarding automatic speed enforcement systems? And why no recommendation that FRA change its PTC regulation so that dispatcher authority, allowing a train to enter a work zone, does not and will not satisfy the requirement for a PTC system to positively prevent unauthorized movement into a workzone?
I'd like to ask NTSB why it takes no notice of MTA's commitment to accelerate its installation of PTC, which acceleration perhaps will lead to operable PTC on MTA's Metro-North and Long Island Railroads sometime in 2017, more than a year after the date mandated by the Rail Safety Improvement Act of 2008?
Might someone incredibly cynical and jaded think that, because NTSB reports to Congress, and there is considerable discussion about Congress pushing out the due date for PTC installation, a shift in emphasis by NTSB might be occurring?
I'm not saying permanent speed signs and medical screening shouldn't be utilized. Indeed they should, as part of a complete safety program that recognizes employees without sleep apnea, employees who know where deceleration must begin for an approaching restriction; good employees with clean records make mistakes and no safety program is robust enough if it does not include correction or enforcement against such mistakes before the mistake becomes an accident.
I like to give credit where credit is due and so I'd like to give credit to the statements of NTSB member Earl F. Weener, Ph.D. Dr. Weener summed up all the points about risk assessment, risk management, audits, inspections, standards, training, protocols in a few sentences: "It all relies on the implementation.... Unless it's applied, it's not very useful."
Exactly. It's all in the execution. That is the reason why the corporate creed that "you can be a good manager without knowing the details of the operation" is so antithetical to safe train operations. You cannot be a good manager without knowing the details of the implementation and execution.
The way to know a railroad's performance is in reviewing, not the results, but the processes by which the railroad conducts its daily business in the delivery of its only product-- safe scheduled service.
November 19, 2014
"Right." Brett, Alien