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Before we continue in our examination of the implementation of C3RS, a little housekeeping is in order. 

By housekeeping, I mean adding a few things, purely non-decorative, that coincide with the themes of my inquiry.   The housekeeping is, more or less, in my own head, so of course, the work is never done.  But this does help control the sort of chain-reaction of  ideas that gets ignited when we perceive in any number of individual incidents, occurrences, etc. a common, systemic issue.  

So, a reader of these columns (believe it or not), who, since confidentiality is of the utmost importance, will only be identified as PN, wrote me:

In my limited experience with construction industry safety programs and insurance underwriting, one principle I learned is that it is the occurrence of an "accident" or "close-call" which defines the risk, or frequency or probability, of the type of event or exposure that could lead to a loss (or liability claim); but that the resulting harm or damages - the magnitude of the loss, of whatever kind - is mere happenstance, the extent of the subsequent fortunate or unfortunate effects being determined by the coincidence of whatever factors saved those involved, or doomed them (as the case may be).  Said another way, there's no such thing as "No harm, no foul"; instead, the occurrence of the foul itself is the critical event that needs to be addressed and corrected, regardless of whether or not any harm resulted.  So the fact that a person or situation was "lucky" and nothing bad happened is of no importance or relevance; it is that the situation occurred at all which is critical to analyze and determine what went wrong and what to do about it.

What can I say after I say "Exactly"? 

The problem with "no harm, no foul" or utilizing the severity of damages as a criteria for evaluating the risk to system safety is just that: system safety is not about damage control.  System safety is about risk reduction.

The same reader was kind enough to provide me with reproduction of the article "Has GR&I No.5 passed Mill Creek?" written by Harold B. Norman from the January 1974 edition of  Trains Magazine. 

That article concludes with a quote from an  editor of a 19th century railroad journal:

The theory that all negligence which causes
serious disaster will always be found to have been more or less habitual is still worthy of respect.

There are no "one-offs" in this business.  Accidents are the results of processes, either  failures to process, or failures of process. 

Which gets me to the next item of housekeeping, and the next quote, this one from the greatest railroad commissioner of Massachusetts, Charles Francis Adams.  This happens to be my single favorite analysis of the conservatism, inertia, near paralysis that seems to infect those of us who should know better when confronting the need for better processes, better systems, better technology: 

At this late day, no board of directors, nor president, nor superintendent has any right to operate a single track road without the systematic use of the telegraph in connection with train movements.  That the telegraph can be used to block, as it is termed, double track roads by dividing them into sections upon no one of which two trains can be running at the same time, is a matter of long and daily experience.  There is nothing new or experimental about it.  It is a system which has been forced on the more crowded lines of the world as an alternative to perennial killings.  That in the year 1879 excursion trains should rush along single track roads and hurl themselves against regular trains just as was done twenty three years ago at Camphill, would be deemed incredible were not exactly similar accidents still from time to time reported.  One occurred near St. Louis, for instance, on July 4, 1879.  The simple fact is that to now operate single track roads without the constant aid of the telegraph as a means of blocking them for every irregular train indicates a degree of wanton carelessness or an excess of incompetence for which adequate provision should be made in criminal law.  Nothing but this appeal to the whipping-post, as it were, seems to produce the needed mental activity, for it is difficult to realize the stupid conservatism of ordinary men when brought to the consideration of something to which they are not accustomed.  On this very point of controlling the train movements on single track roads by telegraph, for instance, within a very recent period,  the superintendent of a leading Massachusetts road gravely assured the railroad commissioners of that state that he considered it a most dangerous reliance which had occasioned many disasters, and he had no doubt it would be speedily abandoned as a practice in favor of the old timetable running rules system from which no deviations would be allowed.  This opinion was expressed, also, after the Revere disaster of 1871, it might have been supposed, had branded into the record of the state the impossibility of safely running a crowded railroad in a reliance upon the schedule.  Such men as this, however, are not accessible to argument or the teachings of experience and the gentle stimulant of a criminal prosecution seems to be the only thing left. (Charles Francis Adams, Notes on Railroad Accidents, 1879). 

We should keep these words, entitled by the author "The Stimulus of Prosecution," clearly in mind when reviewing the claims, credentials, and credibility of all those who rushed Congress to complain about the "unfair," "burdensome," "expensive," "unfunded," "unproven" system called PTC. 

If the gentle stimulus of prosecution is needed, sometimes, to convince railroad management of its obligations, so too is the gentle stimulus of enforcement needed to focus the attention of the railroad's employes on their obligations to safely execute the schedules, the service, of the road.   Enforcement is the most gentle, generous, and just action a railroad can take on behalf of its customers; on behalf of their, and its own system, safety. 

So now we come to this: FRA's Safety Advisory SA 2014-02.

This advisory concerns the "repetitive incidents" involving violations, by one party or the other, of the procedures and protocols for establishing and releasing roadway worker authorities on controlled track. 

Perhaps some will note, as I did, the dramatic reduction in vehemence and volume of the language used in this advisory as compared to the language used by FRA in its open letter, its emergency order, its "deep dive" report directed to MTA and Metro-North Railroad. 

In those documents FRA clearly and repeatedly demanded specific actions by MNR prior to and during the collection of information, regardless of what that information did or did not reveal about the root causes of the decline in safe train operations.

Perhaps some will note, as I did, that although the incidents FRA cited and investigated were particular to MNR, the practices and procedures on MNR were common to many if not most, and most if not all, railroads in the United States, FRA orders only demanded alterations to MNR's practices and procedures. 

Perhaps some will note how gentle, timid even, FRA's recommendations and "advice" are in this advisory when addressed to the entire industry.  

But so much for idle speculation, here's the skinny: 

1.  the advisory incorrectly identifies "Danbury" as the location of the May 2014 fatal accident to a roadway worker on Metro-North.  The accident was nowhere near Danbury, but rather near West Haven, Ct. 

2. On page 70270, "FRA recommends...(3) If a railroad determines that appropriate safety redundancies are not in place..." etc. etc. etc. 

FRA cannot and should not cede the development of "appropriate safety redundancies" to the very railroads where the lack of such redundancies has facilitated  "the infrequent but repetitive incidents involving roadway workers being struck or nearly struck by trains that appear to be due to miscommunication..."  

That determination, as it involves system-safety and industry-wide incidents is the responsibility of FRA.  If 214 and the other regulations do not provide sufficient protection; or if the regulations are not being applied, then the regulations must be enhanced, and their application strengthened. 

FRA, in conjunction with the RSAC, should develop checklists that dispatchers and roadway workers must follow, and compare, which specifically reduce the possibility of these incidents.  The review and comparison of the checklists must be included as part of the authority to establish the work zone, and/or in releasing and clearing a work zone.  Checklists should be utilized regardless of the technical overlays (GPS, EEPS, shunting etc.) utilized to provide redundant protection. 

Checklists are hardly new news. Aviation uses them.  Hospitals adapted them, particularly in surgery and post-surgery care, to reduce the rate of human error that can lead to complications and infections.  Write it down, read it out loud, get the answer, check it off.  It works.  Demonstrably.  

End of housecleaning.  Back shortly.  

November 25, 2014

Words to Prevent Others Dying By

"The theory that all negligence which causes serious disaster will always be found to have been more or less habitual is still worthy of respect"--

author unknown (so far)