Ten90 Solutions LLC

The NTSB has released an open letter to Metro-North Railroad containing its initial safety recommendations derived from the ongoing investigation into the December 1, 2013 derailment of train 8808 which killed four passengers and injured 59 people.

I’d reproduce the letter, or the link to it, but the NTSB decided, in addressing the letter to Joe Giulietti,  Metro-North’s current president, to include Mr. Giulietti’s email address for all the word to see, and copy to its address books.  Nice touch, isn’t that? I really don’t want to add another vector for every bot on the web to use to bombard Mr. Giulietti with invitations for cut-rate Viagra, or chances to purchase penny stocks for just…….well pennies.

The recommendations are that MNR 1) systematically install “approach permanent speed restriction” signs, and presumably “permanent speed restriction” signs and “resume” signs along its right of way.  Although the NTSB does not mention specifically the latter two fixed indicators, those who are conversant with, and responsible for rail operations know we don’t do one, we can’t do one, the approach permanent speed restriction sign, without doing the others. 

Word.

There is nothing wrong, and only good, in installing such fixed indicators, particularly along a railroad which has no fixed automatic signals save those at interlockings.  It’s good to have physical reference points.  The templates for many railroads’ operating rules—GCOR, NORAC, the old Consolidated Code—have provisions for the installation and use of such signs.  There’s nothing wrong, and nothing new, in that.   It costs little, it’s helpful, and of course, to be effective operating a railroad with permanent fixed indications, requires the exact same thing(s) that operating a railroad without these fixed indicators requires: proper training of employees, proper supervision of employees, and proper enforcement in incidents of non-compliance.

The NTSB recommendations do not address those three root (or in today’s jargon, “core”) requisites (or in today’s jargon, “values”) which of course are the same root (or in today’s jargon, “core”) requisites (or in today’s jargon “values) for any, and every, function on a railroad, any railroad (or in today’s jargon, “system”). 

Enough of “today’s jargon,” which has induced successive waves of nausea in me ever since it became popular, which was yesterday, or some collection of yesterdays.  You might call me “old-fashioned” but actually I’m not retro enough to be chic.

So, since that recommendation, helpful and innocuous as it is, doesn’t address the root requisites, the basis  for preserving the vitality of train operations (to use my language), it’s not  likely to have any real significance for the safety of employees and passengers.

In making its recommendation, NTSB gets some of the details wrong—stating for example that “As a result of the accident, Metro-North installed approach permanent speed restrictions signs to aid operating crews at the derailment location,” when in actuality MNR installed a code in the rail triggering a 30 mph speed restriction enforced by the on-board ATC system. 

I know it’s just a detail, but those who are conversant with and responsible for safe train operations know that the devil, the lord, and the vitality of the railroad are all in the details.

Word.

NTSB also fails to mention the impact of FRA’s Emergency Order 29, specifically requiring MNR to provide additional protection in areas where decelerations of 20 mph or greater are required, and the mandatory adaptation of the train control system to enforce such decelerations.

Just another detail.

So much for the first recommendation:  nice, helpful, good, innocuous, and……..superficial.

The second recommendation isn’t new either, but unlike the first, there isn’t a long history of the use of the “inward- and outward- facing audio and image recorders to assist in accidents investigations and with management and regulatory oversight of rules compliance.”

There’s some history, particularly with outward facing video cameras.  These cameras have been quite valuable in recording incidents at grade-crossings and…..signal violations.  As a matter of fact, the UP freight train lead locomotive that was struck by the Metrolink commuter train in Chatsworth, California was equipped with an outward facing video camera.  I’ve seen the video, and if you haven’t, believe me, you don’t want to.

The point, of course, is that while the outward video camera can be helpful after an incident for reviewing the circumstances, and for confirming in all probability what we already know to have occurred from other evidence, it does nothing to prevent the specific incident. 

Short version:  Outward video cameras are of some benefit; a benefit limited to post-accident analysis.

I’m pretty sure that NTSB does not seriously intend for railroads to equip locomotives with “outward-facing” audio recorders.  Just another detail I guess. But maybe not.  So what about inward audio recordings?

Here we confront not just a recommendation of extremely limited value, but a recommendation that is pointless.  First, commuter train operations are overwhelmingly single person cab operations.  Exactly what do we expect to hear from the internal audio recorder?  Snoring?  MP3 players?  Radio transmissions? 

Those of us conversant with and responsible for railroad operations know that railroad radio transmissions involving main line operations are already recorded and available for playback.  So what role would an internal audio recorder play in a) either the investigation of an accident or b) review of employee performance in order to identify failures, weaknesses and thereby prevent a future accident? 

The application of internal video recorders may or may not be pointless, but this is one case where I myself might apply a cost benefit analysis, given the fact that of the extremely paltry return of investment derived from the use of the data available from such recorders.  

Let me explain: If the video record after an incident shows the locomotive engineer utilizing a cell phone, exactly of what significance is that to the current investigation, or future accident prevention, when the data is derived after the fact?  We already have regulations against the use of such devices, and more importantly, we already know a certain number of employees are going to violate those regulations.  So we should already know that our obligation, those of conversant with and responsible for train operations, is to oversee, confirm, and enforce, by and through our repeated and persistent physical presence, to the employees’ compliance with the rules.  And you can’t do that “virtually.”   So exactly what are we going to learn that we don’t already know?

Returning to the Chatsworth collision, does anybody want to watch a video of a locomotive engineer on his cell phone, blowing by a stop signal and colliding head on at 47 mph, with various parts being separated from what was once a whole body?  And the UP engineer?  Do we want to watch what happens to him?  Maybe with a sound track?  Exactly what do we need to hear?  “Oh shit!”???    “JUMP!”??

Short version:  You can’t supervise the railroad “virtually.”  You actually have to be there.  You actually have to know what you’re doing, what you’re supposed to do.  You have to know the details.

NTSB does not recommend real-time monitoring of video recorder data—the transmission of images to a human observer.  Nor does NTSB even acknowledge, much less recommend, that new locomotives and MU locomotives are capable of real time transmission as to location, speed, braking effort, etc.  It would make a least some sense to monitor those operating parameters in real time, even if  the monitoring would present an unmanageable burden to the railroads, given the person-hours required to provide that monitoring.  Such monitoring might actually prevent an accident.  Indeed such “pro-active” (to use today’s jargon) monitoring is the basis for the algorithms that will drive PTC systems.  PTC is where we need to be, or rather, a PTC that defines the limits to one train’s movement authority as the rear end of the train ahead, not “restricted speed” at a signal location.

There’s another aspect of  NTSB orientation that makes this recommendation superficial, and ineffective, at its best.  That aspect is NTSB’s reluctance to acknowledge, support, and endorse  a critical component of enforcement—which is the application of  discipline.

NTSB has been explicit in its criticism of railroads’ “punishment-based” culture  regarding employee failure.  The Board has spoken against the “unjust culture” prevalent on railroads where a “good employee” can, for a first, but serious, violation of the operating rules, face mandatory suspension without pay. 

NTSB isn’t alone in its uncharitable assessment of railroad disciplinary processes.  Associates of the Volpe Institute have made similar evaluations.  Apparently,  FRA has also joined in the chorus at it intends, in its next IMOU for C3RS reporting to include decertifiable offenses (like stop signal violations; like exceeding the limits to a movement authorization)  under the protective umbrella of C3RS.

Well, we, those of conversant with and responsible for safe train operations need to clear the air about this, and refute these characterizations whenever and wherever they arise.  Let’s get this out of the way (this one time) in a hurry.  The fact that a “good employee” can, after years of good service, can be suffer serious consequences for an operating rule violation is not an indicator of an “unjust culture.”  It is an indicator that, indeed, the consequences for an operating rule violation in and of itself can be so much more severe than even the most severe disciplinary rendering.  The consequences can be death, and death to more than just the employee violating the rule.

That’s how we, those of us conversant with and responsible for safe train operations,  judge discipline; that’s how we determine “justice” in our culture.  We, those of us conversant with and responsible for safe train operations, are actually doing the employee a favor.  We are being lenient when we assess a 30 day or 60 day penalty for a serious rule violation.  We, those of us conversant with and responsible for safe train operations, are taking a real risk; a risk that our decision to only suspend, rather than dismiss in all capacities, the employee, will not come back to haunt us. 

The risk, the “haunting” is not confined to simply that individual employee returning to work and violating the same or similar rule with the “penalty” being assessed by the laws of physics against him/her and others who committed no such violation.  The risk and the haunting is that the employees collectively, will ignore, disregard not the disciplinary consequences of a rule violation, but those consequences of the laws of physics if and when we, those of us conversant with and responsible for safe train operations act in anything other than the most serious, determined, and responsible manner. 

Our use of progressive discipline is an attempt at leniency, and it is a conscious acceptance of risk and responsibility, something that some individuals, those not conversant with and responsible for safe train operations may never understand.

 Now that’s  OK, if  they don’t understand it.  Just don’t let it, or them, get in your way.  Don’t let it, or them stop you from meeting your responsibility in removing from service, permanently if conditions so warrant, an employee who represents a threat to the safety of himself/herself and/or others. 

So the next time, someone who has conducted studies on C3RS says to you, as was said to me,  when you question the functioning and the benefits of such a program, “From your questions, you sound like that old school-railroader with that attitude  we’re trying to overcome,”  smile and just say “thank you,”  because I’ll tell you a not so secret secret—the problems some of the commuter railroads are now experiencing are the results of years of trying to “get rid of” that “old-school railroader attitude.”

I have to tell you, if I were running a railroad today, Class 1 or passenger, facing the mandatory implementation of PTC (which I support) at the same time as I am being subjected to such conflicting, and nonsensical pressures regarding enforcement, I really would look to technology rather than supervision for a solution.  And I would look at all this news about drones, drones for Amazon.com deliveries, drones for fire departments, drones for everything, and I would put all that droning together and think how wonderful it would be if I could “drone” my trains—operate all of them no matter where they are remotely, with a joystick, from a single location.  Let the track database, the train handling algorithms, the outward facing video cameras (giving your drone controllers a view of the right of way) actually give you a return for the investment, in this case the return being “no-bang” for the buck.  The controller is there only in case an event arises that the algorithm cannot handle—say a pedestrian trespasser walking along the right of way, not paying attention.

Imagine the “just culture” we could create.  Imagine how little fatigue would be a factor in employee performance.  Imagine how much we could save on “away from home” terminal status; on initial terminal delay; on crew calls; on arbitraries; on training and certification.

I know that’s years away and I’m a dreamer.  But I’m a practical dreamer, and I want to make a practical contribution to accident elimination, so I propose the following.  Since the MOU for C3SR programs specifically exempts “real-time observations” of rule violations from its protective mandate;  and because examination of real-time data can include immediate transmission from a moving train;  and because the amount of real-time data transmitted from moving trains presently exceeds the capacity of immediate railroad response; and because only 60,000 miles of the general railway network will be equipped with PTC systems;  therefore any review of data from any source-- locomotive event recorder,  digital archive and replay of control center’s record of train movements, or review of wireless train data transmissions etc.-- that provides evidence of an operating rule violation will qualify as “real-time observation” and will not be subject to C3SR protections.

That’s what I would do, thoroughly modern old school railroader dreamer that I am, with a thoroughly modern  old-school railroader dreamer attitude for which I’m grateful.  I’d do my level best to put the NTSB out of business.  And that’s an attitude the NTSB should welcome.  

February 19, 2014

Conversant with and responsible for safe train operations.