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Re: [Root_Cause_State_of_the_Practice] Train Signals

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  • Michael Mulligan
    I guess I am wondering how far behind was the second train time wise….Why didn’t the first train tell headquarters that they were diverted to a side
    Message 1 of 4 , Nov 30, 2005
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      I guess I am wondering how far behind was the second
      train time wise….Why didn’t the first train tell
      headquarters that they were diverted to a side
      tract…and why didn’t headquarters figure out the
      actual location of any train on that sector of the
      tracks…ETA…why no auto lockdown of the tracts until
      everything figured out

      Of course you have some sort of proximity device when
      you reposition the tracts…if the employees walked or
      drove past some defined distance…this device would set
      up some sort of alarm on the person…attached to the
      person…and also alarm headquarters.he

      How about an alarming device on the side tract that
      would call up headquaters....where if train got
      diverted... went passed a certain point...it would
      alarm at headquaters.

      thanks,

      mike




      --- cebarnard@... wrote:

      > Any comments on safe approaches to this problem (set
      > of problems - "dark" switches, work sign-out
      > processes, and hazardous cargo...)?
      >
      > Cindy Barnard
      >
      >
      > November 30, 2005
      > Safety Measures Proposed After Train Wreck
      > By MATTHEW L. WALD
      > WASHINGTON, Nov. 29 - To prevent train wrecks like
      > one in January that killed nine people and forced
      > thousands from their homes for days in Graniteville,
      > S.C., railroads should equip tens of thousands of
      > switches in the United States with devices that will
      > "compellingly capture the attention of employees,"
      > the National Transportation Safety Board said
      > Tuesday.
      > In the Graniteville wreck, a crew put a train on a
      > siding at the end of the work day and left a switch
      > aligned so that the next train through also went
      > into the siding.
      > The collision punctured a chlorine tank car, and the
      > gas killed nine people, two of them as they slept.
      > The tracks in the Graniteville area, near Aiken,
      > S.C., were "dark," meaning that they had no
      > electronic signals that would have allowed a
      > dispatcher to realize that the first crew had
      > forgotten to reset the switch. About 40 percent of
      > the rail network is dark.
      > The second train, which was moving at 47 miles an
      > hour in a 49-mile-an-hour zone, would have needed
      > half a mile to stop but had less than an eighth of a
      > mile, investigators said.
      > The engineer, who died in a hospital from chlorine
      > inhalation, was doomed before he got there, they
      > said.
      > A strobe light like those carried on some school
      > buses, or a radio device that sent signals to
      > beepers or cellphones, might have reminded the first
      > crew to reset the switch when leaving the train for
      > the night, investigators said.
      > Members of the crew, coming to the end of a 12-hour
      > workday, had a taxi waiting to take them back to
      > their depot and were anxious about finishing before
      > their work hours would violate federal rules,
      > investigators said.
      > They strayed from the normal pattern of resetting
      > the switch as they moved the train to the next
      > siding, because they were leaving the train in a
      > siding they had not planned to use.
      > As a result, resetting the switch was "now not part
      > of a natural task sequence," said one investigator,
      > Robert Chipkevitch.
      > Debbie Hersman, a member of the safety board who
      > accompanied the investigators to the scene in
      > January, said that the Federal Railroad
      > Administration had proposed fines for failing to
      > reset switches, but questioned the effect.
      > "Do we think these things are going to change
      > operating behavior?" she asked.
      > In fact, the freight railroads recognized the
      > problem even before the Graniteville crash on Jan.
      > 6.
      > The previous October, the Union Pacific and the
      > Burlington Northern-Santa Fe railroads adopted new
      > requirements for train crews when they released
      > their track warrants, which is the railroad
      > equivalent of closing a flight plan, reporting that
      > the trip is complete. Each required that the crew
      > report the position of each switch.
      > In the January accident, the crew violated a rule of
      > their railroad, Norfolk Southern, by failing to have
      > a job briefing that listed the tasks to be performed
      > at the stop in Graniteville.
      > While the Graniteville accident had particularly
      > severe consequences, killing six people working the
      > night shift in a factory by the tracks, a truck
      > driver asleep in his cab and a man asleep in his
      > bed, crashes caused by misaligned switches are
      > common.
      > The board also recommended that railroads put
      > tankers with materials that turn to poison gas,
      > including chlorine and anhydrous ammonia, toward the
      > rear of the train, where they would pose less
      > danger, and reduce speeds through populated areas,
      > to minimize impact forces.
      > The safety board also called for protective masks to
      > be used in emergencies by train crews transporting
      > hazardous materials. > From: "Dr. Bill Corcoran"
      > <William.R.Corcoran@...>
      > To: <Undisclosed-Recipient:;>
      > Subject: [Root_Cause_State_of_the_Practice] Good
      > Safety Culture (GSC) vs. Bad Safety Culture (BSC)
      > Date: Wed, 30 Nov 2005 13:46:48 +0000
      >






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    • Michael Mulligan
      I get it now...the first train was parked there the day before. Wow, causing an accident because of a memory issue....becomes so threatening...because then you
      Message 2 of 4 , Dec 1, 2005
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        I get it now...the first train was parked there the
        day before.

        Wow, causing an accident because of a memory
        issue....becomes so threatening...because then you
        question if something is going on in your
        head…Alzheimer...will it become a repeated
        issue...does it interact with past human
        vulnerabilities of the employees. Imagine how hard it
        would be for a doctor…an engineer.

        It's there big time the fear of not stopping the clock
        on time...and it's very difficult if you are in an
        area where you are not familiar with distance and
        time…like how much time will it take to get to the
        hotel…traffic conditions.

        Did the crew have future scheduling pressures....were
        they running late on the day of their accident? Did
        the supervisor have a lap top and e-mail...you know
        sometime writing about it enhances thinking beside
        verbal communication.



        mike

        --- Michael Mulligan <steamshovel2002@...>
        wrote:

        > I guess I am wondering how far behind was the second
        > train time wise….Why didn’t the first train tell
        > headquarters that they were diverted to a side
        > tract…and why didn’t headquarters figure out the
        > actual location of any train on that sector of the
        > tracks…ETA…why no auto lockdown of the tracts until
        > everything figured out
        >
        > Of course you have some sort of proximity device
        > when
        > you reposition the tracts…if the employees walked or
        > drove past some defined distance…this device would
        > set
        > up some sort of alarm on the person…attached to the
        > person…and also alarm headquarters.he
        >
        > How about an alarming device on the side tract that
        > would call up headquaters....where if train got
        > diverted... went passed a certain point...it would
        > alarm at headquaters.
        >
        > thanks,
        >
        > mike
        >
        >
        >
        >
        > --- cebarnard@... wrote:
        >
        > > Any comments on safe approaches to this problem
        > (set
        > > of problems - "dark" switches, work sign-out
        > > processes, and hazardous cargo...)?
        > >
        > > Cindy Barnard
        > >
        > >
        > > November 30, 2005
        > > Safety Measures Proposed After Train Wreck
        > > By MATTHEW L. WALD
        > > WASHINGTON, Nov. 29 - To prevent train wrecks like
        > > one in January that killed nine people and forced
        > > thousands from their homes for days in
        > Graniteville,
        > > S.C., railroads should equip tens of thousands of
        > > switches in the United States with devices that
        > will
        > > "compellingly capture the attention of employees,"
        > > the National Transportation Safety Board said
        > > Tuesday.
        > > In the Graniteville wreck, a crew put a train on a
        > > siding at the end of the work day and left a
        > switch
        > > aligned so that the next train through also went
        > > into the siding.
        > > The collision punctured a chlorine tank car, and
        > the
        > > gas killed nine people, two of them as they slept.
        >
        > > The tracks in the Graniteville area, near Aiken,
        > > S.C., were "dark," meaning that they had no
        > > electronic signals that would have allowed a
        > > dispatcher to realize that the first crew had
        > > forgotten to reset the switch. About 40 percent of
        > > the rail network is dark.
        > > The second train, which was moving at 47 miles an
        > > hour in a 49-mile-an-hour zone, would have needed
        > > half a mile to stop but had less than an eighth of
        > a
        > > mile, investigators said.
        > > The engineer, who died in a hospital from chlorine
        > > inhalation, was doomed before he got there, they
        > > said.
        > > A strobe light like those carried on some school
        > > buses, or a radio device that sent signals to
        > > beepers or cellphones, might have reminded the
        > first
        > > crew to reset the switch when leaving the train
        > for
        > > the night, investigators said.
        > > Members of the crew, coming to the end of a
        > 12-hour
        > > workday, had a taxi waiting to take them back to
        > > their depot and were anxious about finishing
        > before
        > > their work hours would violate federal rules,
        > > investigators said.
        > > They strayed from the normal pattern of resetting
        > > the switch as they moved the train to the next
        > > siding, because they were leaving the train in a
        > > siding they had not planned to use.
        > > As a result, resetting the switch was "now not
        > part
        > > of a natural task sequence," said one
        > investigator,
        > > Robert Chipkevitch.
        > > Debbie Hersman, a member of the safety board who
        > > accompanied the investigators to the scene in
        > > January, said that the Federal Railroad
        > > Administration had proposed fines for failing to
        > > reset switches, but questioned the effect.
        > > "Do we think these things are going to change
        > > operating behavior?" she asked.
        > > In fact, the freight railroads recognized the
        > > problem even before the Graniteville crash on Jan.
        > > 6.
        > > The previous October, the Union Pacific and the
        > > Burlington Northern-Santa Fe railroads adopted new
        > > requirements for train crews when they released
        > > their track warrants, which is the railroad
        > > equivalent of closing a flight plan, reporting
        > that
        > > the trip is complete. Each required that the crew
        > > report the position of each switch.
        > > In the January accident, the crew violated a rule
        > of
        > > their railroad, Norfolk Southern, by failing to
        > have
        > > a job briefing that listed the tasks to be
        > performed
        > > at the stop in Graniteville.
        > > While the Graniteville accident had particularly
        > > severe consequences, killing six people working
        > the
        > > night shift in a factory by the tracks, a truck
        > > driver asleep in his cab and a man asleep in his
        > > bed, crashes caused by misaligned switches are
        > > common.
        > > The board also recommended that railroads put
        > > tankers with materials that turn to poison gas,
        > > including chlorine and anhydrous ammonia, toward
        > the
        > > rear of the train, where they would pose less
        > > danger, and reduce speeds through populated areas,
        > > to minimize impact forces.
        > > The safety board also called for protective masks
        > to
        > > be used in emergencies by train crews transporting
        > > hazardous materials. > From: "Dr. Bill
        > Corcoran"
        > > <William.R.Corcoran@...>
        > > To: <Undisclosed-Recipient:;>
        > > Subject: [Root_Cause_State_of_the_Practice]
        > Good
        > > Safety Culture (GSC) vs. Bad Safety Culture (BSC)
        > > Date: Wed, 30 Nov 2005 13:46:48 +0000
        > >
        >
        >
        >
        >
        >
        >
        > __________________________________
        > Yahoo! Mail - PC Magazine Editors' Choice 2005
        > http://mail.yahoo.com
        >




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      • Michael Mulligan
        What is the system modeled like….how comprehensive is the tracks and trains modeled at the control center? So you would get a call by the group supervisor
        Message 3 of 4 , Dec 1, 2005
        • 0 Attachment
          What is the system modeled like….how comprehensive is
          the tracks and trains modeled at the control center?
          So you would get a call by the group supervisor saying
          the side track is opened ….or you could automatically
          do it through scheduling…. So the modeled system or
          computer display (GPS)would know that the side track
          is opened….so if a train is anywhere near the opened
          side track….alarms would go off…and if everyone
          ignored the warning….it would kill the juice on the
          train and automatically apply the brakes. Why can’t
          you give the engineer driving the train a visual
          representation of the conditions of the track in the
          same manner…so there are multiple independent
          individuals involve in protecting life and property.

          mike






          --- Michael Mulligan <steamshovel2002@...>
          wrote:

          > I get it now...the first train was parked there the
          > day before.
          >
          > Wow, causing an accident because of a memory
          > issue....becomes so threatening...because then you
          > question if something is going on in your
          > head…Alzheimer...will it become a repeated
          > issue...does it interact with past human
          > vulnerabilities of the employees. Imagine how hard
          > it
          > would be for a doctor…an engineer.
          >
          > It's there big time the fear of not stopping the
          > clock
          > on time...and it's very difficult if you are in an
          > area where you are not familiar with distance and
          > time…like how much time will it take to get to the
          > hotel…traffic conditions.
          >
          > Did the crew have future scheduling
          > pressures....were
          > they running late on the day of their accident? Did
          > the supervisor have a lap top and e-mail...you know
          > sometime writing about it enhances thinking beside
          > verbal communication.
          >
          >
          >
          > mike
          >
          > --- Michael Mulligan <steamshovel2002@...>
          > wrote:
          >
          > > I guess I am wondering how far behind was the
          > second
          > > train time wise….Why didn’t the first train tell
          > > headquarters that they were diverted to a side
          > > tract…and why didn’t headquarters figure out the
          > > actual location of any train on that sector of the
          > > tracks…ETA…why no auto lockdown of the tracts
          > until
          > > everything figured out
          > >
          > > Of course you have some sort of proximity device
          > > when
          > > you reposition the tracts…if the employees walked
          > or
          > > drove past some defined distance…this device would
          > > set
          > > up some sort of alarm on the person…attached to
          > the
          > > person…and also alarm headquarters.he
          > >
          > > How about an alarming device on the side tract
          > that
          > > would call up headquaters....where if train got
          > > diverted... went passed a certain point...it would
          > > alarm at headquaters.
          > >
          > > thanks,
          > >
          > > mike
          > >
          > >
          > >
          > >
          > > --- cebarnard@... wrote:
          > >
          > > > Any comments on safe approaches to this problem
          > > (set
          > > > of problems - "dark" switches, work sign-out
          > > > processes, and hazardous cargo...)?
          > > >
          > > > Cindy Barnard
          > > >
          > > >
          > > > November 30, 2005
          > > > Safety Measures Proposed After Train Wreck
          > > > By MATTHEW L. WALD
          > > > WASHINGTON, Nov. 29 - To prevent train wrecks
          > like
          > > > one in January that killed nine people and
          > forced
          > > > thousands from their homes for days in
          > > Graniteville,
          > > > S.C., railroads should equip tens of thousands
          > of
          > > > switches in the United States with devices that
          > > will
          > > > "compellingly capture the attention of
          > employees,"
          > > > the National Transportation Safety Board said
          > > > Tuesday.
          > > > In the Graniteville wreck, a crew put a train on
          > a
          > > > siding at the end of the work day and left a
          > > switch
          > > > aligned so that the next train through also went
          > > > into the siding.
          > > > The collision punctured a chlorine tank car, and
          > > the
          > > > gas killed nine people, two of them as they
          > slept.
          > >
          > > > The tracks in the Graniteville area, near Aiken,
          > > > S.C., were "dark," meaning that they had no
          > > > electronic signals that would have allowed a
          > > > dispatcher to realize that the first crew had
          > > > forgotten to reset the switch. About 40 percent
          > of
          > > > the rail network is dark.
          > > > The second train, which was moving at 47 miles
          > an
          > > > hour in a 49-mile-an-hour zone, would have
          > needed
          > > > half a mile to stop but had less than an eighth
          > of
          > > a
          > > > mile, investigators said.
          > > > The engineer, who died in a hospital from
          > chlorine
          > > > inhalation, was doomed before he got there, they
          > > > said.
          > > > A strobe light like those carried on some school
          > > > buses, or a radio device that sent signals to
          > > > beepers or cellphones, might have reminded the
          > > first
          > > > crew to reset the switch when leaving the train
          > > for
          > > > the night, investigators said.
          > > > Members of the crew, coming to the end of a
          > > 12-hour
          > > > workday, had a taxi waiting to take them back to
          > > > their depot and were anxious about finishing
          > > before
          > > > their work hours would violate federal rules,
          > > > investigators said.
          > > > They strayed from the normal pattern of
          > resetting
          > > > the switch as they moved the train to the next
          > > > siding, because they were leaving the train in a
          > > > siding they had not planned to use.
          > > > As a result, resetting the switch was "now not
          > > part
          > > > of a natural task sequence," said one
          > > investigator,
          > > > Robert Chipkevitch.
          > > > Debbie Hersman, a member of the safety board who
          > > > accompanied the investigators to the scene in
          > > > January, said that the Federal Railroad
          > > > Administration had proposed fines for failing to
          > > > reset switches, but questioned the effect.
          > > > "Do we think these things are going to change
          > > > operating behavior?" she asked.
          > > > In fact, the freight railroads recognized the
          > > > problem even before the Graniteville crash on
          > Jan.
          > > > 6.
          > > > The previous October, the Union Pacific and the
          > > > Burlington Northern-Santa Fe railroads adopted
          > new
          > > > requirements for train crews when they released
          > > > their track warrants, which is the railroad
          > > > equivalent of closing a flight plan, reporting
          > > that
          > > > the trip is complete. Each required that the
          > crew
          > > > report the position of each switch.
          > > > In the January accident, the crew violated a
          > rule
          > > of
          > > > their railroad, Norfolk Southern, by failing to
          > > have
          > > > a job briefing that listed the tasks to be
          > > performed
          > > > at the stop in Graniteville.
          > > > While the Graniteville accident had particularly
          > > > severe consequences, killing six people working
          > > the
          > > > night shift in a factory by the tracks, a truck
          > > > driver asleep in his cab and a man asleep in his
          > > > bed, crashes caused by misaligned switches are
          > > > common.
          > > > The board also recommended that railroads put
          > > > tankers with materials that turn to poison gas,
          > > > including chlorine and anhydrous ammonia, toward
          > > the
          > > > rear of the train, where they would pose less
          > > > danger, and reduce speeds through populated
          > areas,
          > > > to minimize impact forces.
          > > > The safety board also called for protective
          > masks
          > > to
          > > > be used in emergencies by train crews
          > transporting
          > > > hazardous materials. > From: "Dr. Bill
          > > Corcoran"
          > > > <William.R.Corcoran@...>
          > > > To: <Undisclosed-Recipient:;>
          > > > Subject: [Root_Cause_State_of_the_Practice]
          >
          === message truncated ===





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          Yahoo! Mail - PC Magazine Editors' Choice 2005
          http://mail.yahoo.com
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