Sad - Amtrak employee killed on duty Oct 29

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acelafan

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This is a sad news story - didn't see it posted today in AU.

http://www.news10.com/story/27156938/amtrak-employee-killed-while-on-duty

Amtrak employee killed while on dutyPosted: Oct 29, 2014 4:46 PM EDT

CLERMONT, N.Y. – Amtrak confirmed an employee was struck and killed by an Amtrak train Wednesday morning. The Columbia County Sheriff said deputies were dispatched just before 11:15 a.m. on Wednesday for a train/pedestrian fatality in the area between Germantown, N.Y. and the Dutchess County line. Officers located the accident scene in the town of Clermont.

...
 

jis

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PRR 60

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Sadly, an accident like this is virtually inevitable within a culture that does not truly value safety. Yes, I know the Amtrak says all the right things, but time after time there are reports of crews relieved due to safety violations. Too often you hear Amtrak people minimize those events with such responses as "no one got hurt" or "humans sometimes make mistakes." Earlier this year, Joe Boardman sent out a memo that pleaded with employees to up their safety awareness.

Among safety professionals, there is a philosophy called the pyramid of safety. The base of the pyramid are simple violations. Those build toward the middle, which are accidents that do not result in injury. Finally, at the top of the pyramid, the bad outcome occurs, with someone badly hurt or killed. Tolerance of each of the lower levels builds the pyramid and leads to the bad accident at the top. Eliminate the excuses, stop the issues at the bottom of the pyramid, and you do not get to the top.

Here are the 2013 FRA stats comparing Amtrak to the other Class 1 railroads for the number of employee cases per 200,000 hours worked. The numbers are pretty revealing. The lower numbers are indicate better safety performance.

Amtrak - 4.08

BNSF - 1.10

CN - 1.89

CP - 2.17

CSX - 0.91

KCS - 1.82

NS - 1.17

UP - 1.15

Amtrak, by far, has the worst employee safety record of any Class 1 railroad. Amtrak is more than twice as bad as the average for all the other Class 1's. It is more than four times as bad as the industry leader.

This type of performance is always a cultural issue. The rules and procedures are there, but for various reasons, the adherence to those rules is lacking. This is a management failure. A few months ago, a senior Amtrak executive was discharged due to safety issues within his department. It would appear that some additional actions need to be taken. The entire organization has to be made aware that safety is number one and overrides all other priorities: that everyone from the top down will be held accountable.

An Amtrak employee went to work yesterday and did not come home. There is no question it could have been prevented. No matter what the final outcome of the investigation, no matter who is found "at fault", Amtrak management is to blame.
 

Devil's Advocate

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Safety is also a balancing act. If you don't push safety hard enough employees can become shockingly complacent. If you push too far employees may initially comply but will eventually look for ways to sidestep or circumvent the rules, potentially creating an even worse situation. I've had to visit several potentially dangerous locations on numerous occasions as part of my job and never lost so much as the tip of a fingernail. That being said I've probably broken more than a few safety rules over the years without even realizing it. I'm at IT guy who spends most of his time in an office so I'm not fully aware of all the various ways a given piece of heavy machinery can bash, blend, or bake me to death. The sheer number of ways someone can die on the job is truly staggering. In my situation the primary protections are hard hats, steel toe boots, high visibility, and using your brain. The last thing I want is to become one of those "Don't let this happen to you!" poster children who suffers an easily preventable death only to live on in infamy as a teaching moment for others.
 

jis

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Incidentally, this incident apparently took place in 100mph territory. Everyone who are conversant with the rules are quite mystified as to how a single unprotected by anyone else, person could be out on the tracks with no protection in place of the track. The safety protocol breach apparently was apparently of epic proportions and there may be some serious consequences flowing out of this. NTSB is involved. Amtrak Empire Division could face the same scrutiny that MNRR has been going through the last several months.
 

Thirdrail7

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Sadly, an accident like this is virtually inevitable within a culture that does not truly value safety. Yes, I know the Amtrak says all the right things, but time after time there are reports of crews relieved due to safety violations. Too often you hear Amtrak people minimize those events with such responses as "no one got hurt" or "humans sometimes make mistakes." Earlier this year, Joe Boardman sent out a memo that pleaded with employees to up their safety awareness.

Among safety professionals, there is a philosophy called the pyramid of safety. The base of the pyramid are simple violations. Those build toward the middle, which are accidents that do not result in injury. Finally, at the top of the pyramid, the bad outcome occurs, with someone badly hurt or killed. Tolerance of each of the lower levels builds the pyramid and leads to the bad accident at the top. Eliminate the excuses, stop the issues at the bottom of the pyramid, and you do not get to the top.

Here are the 2013 FRA stats comparing Amtrak to the other Class 1 railroads for the number of employee cases per 200,000 hours worked. The numbers are pretty revealing. The lower numbers are indicate better safety performance.

Amtrak - 4.08

BNSF - 1.10

CN - 1.89

CP - 2.17

CSX - 0.91

KCS - 1.82

NS - 1.17

UP - 1.15

Amtrak, by far, has the worst employee safety record of any Class 1 railroad. Amtrak is more than twice as bad as the average for all the other Class 1's. It is more than four times as bad as the industry leader.

This type of performance is always a cultural issue. The rules and procedures are there, but for various reasons, the adherence to those rules is lacking. This is a management failure. A few months ago, a senior Amtrak executive was discharged due to safety issues within his department. It would appear that some additional actions need to be taken. The entire organization has to be made aware that safety is number one and overrides all other priorities: that everyone from the top down will be held accountable.

An Amtrak employee went to work yesterday and did not come home. There is no question it could have been prevented. No matter what the final outcome of the investigation, no matter who is found "at fault", Amtrak management is to blame.

I'll take this one. Prr60, while you are entitled to voice your opinion based upon the information you presented, please realize your comparison is apples to oranges. Comparing freight operations to a passenger operation is ludicrous. A train went into emergency after hitting debris and the chef cut his finger. Obviously, this is a reportable injury. If this is a freight crew, you have two or three people at risk assuming this isn't remote control operations. On an Amtrak train, you may have 5 to 8 people at risk, so it is natural you'll have a higher injury ratio than a freight operation so your figures are hardly conclusive. A better comparison (and I would still imagine Amtrak would have more reportable injuries) would likely involve other passenger railroads.

Secondly and most important is the fact that under Boardman's reign, injury reports are encouraged! This is a far cry from the tactics employed by some of the aforementioned railroads and even Amtrak under other leaders. Injuries are no longer downplayed or swept under the rug by leaders trying to keep the numbers low to qualify for performance bonuses and employees no longer fear being fired or harassed for making reports. In some cases, employees don't even wish to file claims and management insists...just as precautionary.

More than a few of the railroads you listed above (and some that you didn't list ) have been fined (on multiple occasions in some cases) for retaliating against employees that report injuries and unsafe conditions.

Low numbers mean very little.
 

jis

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I have not looked at this recently, but when I looked at it several years back, among passenger railroads, Amtrak was not actually too bad. It was about middle of the flock with several commuter roads far worse than Amtrak. As usual there is always room to improve. Of course one thing that I don't know is whether injuries to OBS crew and T&E and maintenance crew are lumped together in the reporting or not. If that is the case what happens when the OBS crew is not Amtrak employed as in some of the state operations? I don't know for sure and would like to be educated about such.
 
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FormerOBS

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Thirdrail: You beat me to the punch. Your points are very much to the point, and I was going to say some of the same things. The freight railroads mentioned do not operate in the 100 mph speed ranges, so high-speed accidents simply don't happen. A freight train may have two employees aboard, and sometimes even fewer (as at Lac Megantic); a passenger train will have at least double that number. The freight crew is confined to one area --- the cab --- and the passenger train crew are dispersed throughout the train. Of course, this accident happened down on the track, but the stats cited above are overall stats where these factors do come into play.

The old saying "The rulebook was written in blood" was drummed into us from Day 1. Sometimes we made mistakes, and I've seen overt rule violations, but we always tried to work safely for our own sakes and that of our passengers and coworkers.

It's a very sad day.

Tom
 

andersone

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I work at a VPP "Star of Excellence" company which in English is about as safety oriented a company as there is. I have been actively involved in that effort and understand fairly well what it takes to work safely around some very hazardous stuff. Granted it isn't moving at 100 miles an hour, but is pretty nasty and you don't want to go home with it on your shoes.

We have only achieved this milestone (one of 6 contractors for one of the larger federal agencies to achieve this status) because everyone, from the Program Manager to the folks sweeping the floors (in a highly union enviro I might add) have assimilated into a culture a safety. We have more than a million hours without a lost time because we not only believe but we act on the basis that if you keep me safe I will keep you safe.

Whatever the root cause may be of this tragedy, it is the responsibility of management to create a safety culture that pervades every aspect of work. Around here, the only thing that trumps safety is security, but they better be careful how they do it. I can only hope this tragedy sparks a commitment from management to change the Amtrak safety culture so that everyone can go home safe tonight.

My condolences to the family, and friends of the victim
 

neroden

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I was on this train (#280 of Wednesday October 29), trying to get to a funeral for a friend who died suddenly and unexpectedly from unknown causes. We did not get to the funeral thanks to Amtrak's incompetence.

I am not sympathetic to Amtrak. The signal worker -- in contrast to my friend -- must have died due to flagrant violations of safety protocol. I do feel sorry for the engineer, who was clearly extremely upset. We still don't know who was violating the safety protocol -- the dead worker himself is most likely (suicide perhaps?), but it could have been the foreman or the dispatcher or (unlikely) the engineer or conductor, or another signal maintainer or locomotive maintainer (leaving the signal system in an unsafe state, for instance). The NTSB will probably have a report.

Amtrak Penn Station did not handle the aftermath of this incident competently. Obviously there was a long delay (upwards of 3 hours) at the site, and a recrewing. Then, apparently the federal government decided to "quarantine" the locomotive, so the passengers all had to get off at Rhinecliff (low platform!!) and get onto a different train (a third crew).

This is the point at which Penn Station proved to be unwilling or unable to do their job. Amtrak did not accomodate passengers properly. We had an hour and a half before we got to Penn Station at that point. Despite my repeated attempts to get information, Amtrak provided zero accurate information on rescheduling and connections after we finally got moving from Rhinecliff -- and even after we arrived in Penn Station, and even half an hour *after* we arrived in Penn Station. On the train, we were finally (shortly before boarding) given inaccurate information as to where to go. In the station, we were told repeatedly that a manager would come, and there was no manager. Eventually I got the name of the theoretical, absent, manager (Mark Jordan). I got a hotel myself, and got dinner -- which we needed at this point due to hypoglycemia, it being 4.5 hours after our train was supposed to arrive. Then I called customer relations to try to get Mark Jordan fired. The customer relations agent was shocked at the behavior of the Penn Station staff, set up a report to send to Mark Jordan's boss, so hopefully something will happen to change this. (At least the Customer Relations agent comped us our return tickets, refunded all onward tickets without fee, and is reimbursing us for our hotel rooms -- the minimum reasonable response.)

I've been in a lot of trains severely delayed for a lot of reasons, but I was always going through Chicago. Chicago always had a decent plan for handling passengers which involved communicating with us. It seems that you simply can't trust connections through NY Penn Station, because if there's a problem which imperils your connection, they won't even tell you what they're planning to do.

The ClubAcela people kept saying "Someone died" as if this was an excuse for Penn Station's incompetence -- which it isn't. Yeah. My friend died. And Amtrak didn't get me to her funeral, because Amtrak Penn Station managers didn't do their jobs. Some dangerous idiot who violated safety protocols is not an excuse for failing to do your jobs.

I give full credit to the conductors on all three crews, who were all very professional and all doing their absolute best under very trying circumstances. Unfortunately they couldn't get information out of Penn Station any more than I could. The reservations agents at 1-800-USA-RAIL couldn't get any information out of Penn Station either. And of course I couldn't get any information even when I was there. Penn Station management is a black hole.

Have we mentioned that (lack of) communications is one of Amtrak's biggest problems?
 
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neroden

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Incidentally, this incident apparently took place in 100mph territory. Everyone who are conversant with the rules are quite mystified as to how a single unprotected by anyone else, person could be out on the tracks with no protection in place of the track. The safety protocol breach apparently was apparently of epic proportions and there may be some serious consequences flowing out of this. NTSB is involved. Amtrak Empire Division could face the same scrutiny that MNRR has been going through the last several months.
Suicide seems more likely than anything else, honestly. There has to be an investigation, of course, because one doesn't expect signal maintainers to commit suicide at their workplace.

I don't know the exact rules on this division, but rules are generally designed so that it requires two different points of failure (two different systems or people have to fail) in order to allow someone on the tracks when a train is coming (or allow a train to come when someone is on the tracks). But of course a suicidal person can always jump on the tracks when he knows a train is coming, all by himself.
 
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neroden

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A few months ago, a senior Amtrak executive was discharged due to safety issues within his department.
Which department? Was it perchance the signalling department?
I remember reading about the incident in Michigan where "signal maintainers" left the signal system in an unsafe state. That was very, very, very bad. The fact that this incident also involves a signal maintainer... makes me wonder.

Signalling demands the absolute highest standards of safety of any part of the railroad, even higher than the standards for T&E crew. Signal designers and maintainers are, fundamentally, responsible for the safety of everyone traversing or crossing the railroad. Everyone else is relying on them. One mis-wiring can, potentially, crash a dozen trains. Sloppiness in the signal maintenance department is not tolerable.
 
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jis

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Penn Station has developed quite a reputation

Incidentally, this incident apparently took place in 100mph territory. Everyone who are conversant with the rules are quite mystified as to how a single unprotected by anyone else, person could be out on the tracks with no protection in place of the track. The safety protocol breach apparently was apparently of epic proportions and there may be some serious consequences flowing out of this. NTSB is involved. Amtrak Empire Division could face the same scrutiny that MNRR has been going through the last several months.
Suicide seems more likely than anything else, honestly. There has to be an investigation, of course, because one doesn't expect signal maintainers to commit suicide at their workplace.

I don't know the exact rules on this division, but rules are generally designed so that it requires two different points of failure (two different systems or people have to fail) in order to allow someone on the tracks when a train is coming (or allow a train to come when someone is on the tracks). But of course a suicidal person can always jump on the tracks when he knows a train is coming, all by himself.
If you get a chance jump onto trainorders.com and look at the thread on this there. There is a very knowledgeable guy who has posted exactly what the rules are.

BTW, Penn Station managers seem to have developed quite a reputation over the last year for their collective lack of competence. They also managed to somehow send all the passengers for an Acela to the wrong platform a few months back. only those that did not follow their kindergarten march were the ones that got on the train, which simply left without the others under the able guidance of the ushers. They were offered pizza for their troubles as I seem to recall.
 

neroden

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Uh-oh. I don't like the look of those generic federal rules.

(from "Out of Service" on trainorders): "there are 3 scenario requirements of protection for track bridge & signal inspectors ... walking track outside interlocking limits with more than 15 seconds of warning to clear the track ... walking alone or with watchman protection with less than 15 seconds to clear under track Foul Time or with track Out Of Service ..."

15 seconds isn't long enough. The track in question is next to a sheer vertical rockface; the only escape involves crossing the other track. And the trains run very fast through here; even a watchman isn't of much use.

If anyone is on that track, trains should be held out of the block until the dispatcher verifies that the workers are clear.

The quoted generic federal rules would be considered not to qualify as safeworking by British standards. They are not fail-safe, and in the special situation where there is nowhere to jump at trackside, they are not even safe when applied properly.

I certainly hope that Amtrak has some much more specific rules for trackworker access to the narrow parts of this division, akin to the rules used for trackworker access to tunnels.
 
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jis

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I agree. The federal rules should be considered a base to build upon. Each railroad should develop rules that address their special cases properly. The railroads of the northeast have been used to such due to the myriads of special situations they face.
 

Karl1459

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Oversimplifing the fault matrix:

A. The train was not supposed to be where it was.

1. Train operator error.

2. Dispatcher error.

3. Signal system failure.

B. The employee was not where she was supposed to be.

1. Supervisor error.

2. Employee error.

3. Employee intent.

4. Secondary failure causing employee to be where she was not supposed to be.

a. third party intent.

b. failure of some kind of safe zone area/equipment.

Until the full accident investigation, or at additional facts become available all we can do is speculate foam.
 

neroden

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Good description. B2/B3 is the one we expect when a train hits someone. Any of the others would cause a very serious investigation into Amtrak procedure, because they should not happen ever.
 

jis

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Good description. B2/B3 is the one we expect when a train hits someone. Any of the others would cause a very serious investigation into Amtrak procedure, because they should not happen ever.
But should be eliminated as possibility only after given due consideration in the investigation. Within the last two years there have been cases of all of the As and even B1, fortunately not causing any fatalities, but has caused injuries.
 

neroden

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But should be eliminated as possibility only after given due consideration in the investigation. Within the last two years there have been cases of all of the As and even B1, fortunately not causing any fatalities, but has caused injuries.
Yeesh. All of these in the last two years? That does show signs of serious problems with a lack of "safety culture".

B1 is especially terrible, and should have a zero tolerance policy. A2 and A3 are very bad too; however, in a well-run system, the signal system and the dispatcher should be partially redundant, so that a dispatcher error is caught by the signal system, and a signal system failure is caught by the dispatcher.
 
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