Washington subway crash

[wolf]

I think they don't bother because 99.9998% of rail crashes are attributed to operator error. Not saying that's the actual cause, just saying that's where the blame is laid.

[dar512]

I think you're a bit hasty in flipping the bozo bit, Glatt. I didn't see anything in that article that says that they've been able to reproduce the conditions that caused the accident. And I can tell you from experience that debugging can be hard. Especially so when you've got hardware and software involved. Not to mention that part of the circuit is train tracks that live outdoors.

Before pointing and laughing at these folks I'd want to know if they have access to all the circuitry and microcode involved. If they don't, they're trying to debug this thing blind. I'd also like to know if they've been allowed to try to reproduce this under working conditions. They may not. Metro may not want to risk squishing one or two of their trains to find the answer to this issue.

[Shawnee123]

Certainly it's an intricate dealing. You think there'd be a flowchart or something.

[classicman]

...or a graph! We like graphs

[glatt]

Originally Posted by dar512

I didn't see anything in that article that says that they've been able to reproduce the conditions that caused the accident.

It wasn't in the article I just linked to, but there was a test shortly after the accident that recreated the conditions and the result was identical to the crash, except they didn't actually smash the trains together.

Article about it here. Three months ago.

Investigators with the National Transportation Safety Board performed the simulation Wednesday night. In the test, investigators positioned a train in the same location as the train that was rear-ended Monday. The system failed to detect that the idled test train was there

I know it's not easy to figure out, and they are only human, but it's been 3 months. They have had the track closed to train traffic for that entire time, available for study. It's just sitting there. They have to single track around the site and it's causing serious delays for the poor saps on the Red line.

The sensor manufacturer is Alstom Signaling, and it's some sort of problem with their sensors. Or a problem with how their sensors are installed into the system.

Shawnee is right with her o-ring joke. We need Richard Feynman to stick one of these sensors into a glass of ice water and figure it out.

[glatt]

Just for the record, they finally opened that stretch of track this week. But they still don't know what's wrong with the sensors, so all the trains are still being operated manually. My guess is that this is now how things are going to run on the system. The new standard.

[Clodfobble]

...Right up until a negligent train driver causes a wreck, and they suddenly decide that what we really need for safety is computer automation...

[tw]

Originally Posted by Shawnee123

You think there'd be a whole system in place for testing and calibration and errors and fixes...scary.

From the Washington Post of 23 Oct 2009:

Metro to test new software for crash-avoidance system
After a fatal Red Line crash in June, federal investigators said Metro's crash-avoidance system was inadequate and called for the agency to implement a real-time backup. …
Metro uses a software program to check for circuit malfunctions. Since the Red Line crash, those software checks have been run twice a day to look for anomalies. If problems are found, crews are sent to inspect the circuit; if necessary, adjustments are made on the spot.

No problem! If a collision avoidance system fails, a program will discover it up to 12 hours later. IOW report why those two trains collided. 85% of all problems are directly traceable to top management. When management is technically dumb, then a protection system (that does not execute during the rush hour and only operates twice a day) is more than sufficient.

After all, trains don’t collide. When the collision avoidance system failed repeatedly previously, trains did not collide. Therefore don’t worry; be happy. What any management says when employees work for them.

Some believe the operator was at fault. Even that is often directly traceable to top management that did not provide the necessary atttitude and knowledge.

[tw]

Another indication of a company that may have management problems. From ABC News on 23 Oct 2009:

Cockpit Voice Recorder Unlikely to Provide Answers in Northwest Overshoot
Investigators trying to determine why two Northwest Airlines pilots were out of contact with air traffic controllers for more than an hour Wednesday night might have a hard time trying putting all the pieces together. ...

Asked how many years of service the pilots have and how many hours they were into their shift, a Delta spokesman said, "We are not sharing as that is all part of the investigation." ...

Monday at 6:05 a.m., Delta flight 60 from Rio de Janeiro to Atlanta landed on a taxiway instead of the parallel runway where it was supposed to touch down.

[tw]

Management failures continue in the Washington Metro system. Over a month ago, a track worker was killed. Trains are supposed to be notified of track work ongoing, also see warning signs that track workers are ahead, and slow to 10 MPH in that construction area. And yet many workers note trains fly through construction areas at 50 MPH - full speed.

Death only in the Washington Metro account for over 40% of all American railroad workers. The 22 Jun crash and death of six passengers did what? Yesterday, add two more deaths. From the Washington Post of 27 Jan 2010:

NTSB investigates Red Line accident that killed 2 Metro track workers
Federal officials investigating the deaths Tuesday of two Metro employees are trying to determine why the driver of a Metro utility vehicle did not know that the men were working behind him on the tracks. ...
Five Metro workers have been killed on the tracks in the past seven months. The safety problems, including a Red Line crash June 22 that killed nine people, have triggered an upheaval in Metro's leadership ...
Tuesday's accident occurred about 2 a.m. near the Rockville Station when a truck, modified to operate on the rails and moving in reverse, backed into two technicians who were working on the tracks as part of a separate crew.

How often do so many failures continue until someone views the only common factor in all events? Death and near death stories have been almost monthly now on the Washington area Metro. From the Washington Post of 8 Jan 2010:

Report finds slapdash safety culture at Metro
ANEW REPORT by the agency that monitors safety on Metro makes chilling reading -- nearly as chilling as the experience of some of the safety inspectors who helped write it. One team of inspectors was nearly run down by an onrushing Metro train on the tracks last month even as it was examining safety conditions for Metro track workers. According to the inspectors, the operator of the train made no attempt to slow down, let alone stop, or even to acknowledge the presence of the inspectors who had to scramble out of the train's path to safety.

That incident, which took place Dec. 10, sheds light on the some factors that have contributed to the deaths of six Metro workers hit by trains since October 2005, including two who were killed in the past five months even as the agency was conducting its review of track workers' safety. ...

They also extend to what appears to be a perverse culture when it comes to safety at Metro, in which train operators and track workers regard each other with open antagonism; Metro safety classes do not bother to teach Metro's own safety rules; and the transmission and accuracy of critical information -- for instance, the presence and location of track workers in the path of trains -- is slipshod and unreliable.

They are not called accidents. They are murder. But when a murder is directly traceable to top management, then we call it an accident.

The review found that train operators were speeding up rather than slowing down, as required, as they approached track workers who had not been fully cleared from the track right of way.

That attitude should result in assault (if not murder) charges. So weeks after the chilling report, what happens? "Two more dead in Maryland"

What did the Navy do when problems existed. Navy had a three day stand down of the entire Navy. Management addressed problems directly traceable to top management.

How did Marchionne fix Fiat? In sixty days he fired all top management. Therefore Fiat became so productive as to even buy Chrysler. Only public silence can explain so many Washington Metro murders - especially when investigations have made the reasons so flagrantly obvious.

[glatt]

The incident this week was caused by human error. There was supposed to be a lookout on the work crew watching for oncoming rail traffic. That publicly unidentified person was not doing his/her job. That's not management, that's worker incompetence. A lazy co-worker killed those two track workers the other night. The track maintenance truck that backed over them was going in reverse and had limited visibility. The track workers were supposed to be watching for it.

But I suppose you are right. Management should identify the slacker lookout and punish him/her and make sure everyone else is doing their job.

Metro is fucked right now. It's seeing reduced ridership because of the economy and because some people are turned off by all the safety problems. So it has reduced revenue. They are holding public hearings shortly to discuss whether they should cut service, or raise prices, or both. That's going to hurt them even more as it pushes more riders into their cars.

[tw]

Originally Posted by glatt

But I suppose you are right. Management should identify the slacker lookout and punish him/her and make sure everyone else is doing their job.

If that rear observer is not there, the driver should stop. IOW at least two people were violating the rules. But then read the comments from third parties. For example, the wife notes employees were not even provided working safety straps. Employees are ordered to sign off on safety training that was never provided. And threatened by management if they do not sign to a lie.

These are not accidents. Employee actions are directly traceable to 'attitude and knowledge' which only management defines. That is a management primary responsibility as even defined by William Edward Deming. To provide the attitude and knowledge. Even Federal inspectors noted how employees would speed up when safety runs demand they slow to 10 MPH - because even inspector lives were threatened by employee safety violations.

One employee may be a personnel problem. Routine violations - that is only blatant management failure.

Six deaths on 22 Jun before this got any attention? Washington area residents should be screaming for the heads of all senior Metro management. Instead, mostly silence. And a post that blames an employee for doing what is apparently routine.

Meanwhile, that truck must also have a beeper when backing up. No beeper apparently meant two workers never knew the truck was coming. Even the workers could not protect themselves. A construction truck without that backup beeper should never even leave the shop - if management is doing its job.

[tw]

From the Washington Post of 13 Feb 2010:

Safety system derails D.C. Metro train on wrong track
A Red Line train leaving the Farragut North Station on Friday morning ended up on the wrong track and was automatically derailed by safety devices to prevent a possible collision with another train, according to Metro sources familiar with events. ...

After leaving Farragut North, the train left the main track and went onto a short stretch of track, known as a pocket track, which is similar to a breakdown lane on a highway. Trains are often routed to a pocket track when something is occurring ahead of them and they should not proceed.

Although it is not clear why, controllers in Metro's downtown control center had set the switch to route the train onto the pocket track, according to a Metro source, who did not want to be identified because the incident is under investigation.

That source and another Metro source said the train operator had failed to stop at a red signal on the main track. According to procedure, the operator should have stopped and contacted the control center. ...

In November, records showed that Metro had quietly barred safety monitors from walking along its live tracks to assess Metro's compliance with its own safety rules. During the ban, two workers were hit on the tracks and fatally injured. In late January, two more Metro workers were fatally injured when struck by a utility vehicle on the tracks.

An analysis by The Post of safety data showed that more than 100 Metro safety flaws -- identified after audits, accidents and other incidents -- had gone uncorrected.

[glatt]

Thanks for that info tw. I hadn't gotten around to looking up further reports about why that train derailed.

I rode metro yesterday, and it was really bizarre what they were doing. They were running trains every 25 minutes, instead of every 5 minutes, due to some problem with the snow, so they only had a 5th of their normal capacity. There were dark trains parked in a couple of the stations underground, so they were switching the live, passenger carrying, trains around the dead ones. When I arrived at my normal station in the suburbs to begin my commute, they had cones set up to force all passengers to the tracks that are normally outbound. So when the crowded train came 25 minutes later, it was coming from the "wrong" direction for that track.

The frustrating thing was that they could have been running 8 car trains so that more people would fit on each one, but the trains were only 6 car trains.

I left work 2 hours early to beat the inevitable horror show that was obviously coming at the end of the day, and got home fine, but the paper this morning has front page news of the horrible evening commute. The federal workers who went in at staggered times on a delayed opening in the morning all left at exactly the same time at the end of the day and gridlocked the city and overwhelmed the Metro.

[ZenGum]

What a way to run a railroad!

In our hippy-fascist social utopia Down Under, senior management can be held criminally liable for workplace deaths. The charge isn't "murder" but can still result in prison. Do you have that in the Great Satan?