Washington subway crash

[glatt]

My understanding from what little I've read about the bakes is that when the train is in automatic mode, driven by the computer, you apply the brakes by hitting the panic button. The brakes then go on with full force and don't come off. It's an all or nothing emergency brake.

Gradual braking can only be done if the train is in manual mode and the driver is actually driving.

During the crash, this train was in automatic mode.

There's something strange going on if the skid marks stop and then continue again.

[tw]

Originally Posted by glatt

There's something strange going on if the skid marks stop and then continue again.

Your picture shows the same thing. The bluing of steel rails are marked where it started and stopped. I can think of maybe five different reasons for this. For example, the braking system adjusts for maximum braking after first locking the wheels. Or the operator ran for her life (which is not supported by anything in witness testimony or in the operator's body). Or it is normal for bluing to stop once the wheels get so hot. Or ...

It simply remains a curious question. I saw nothing that explains that behavior.

Most curious is testimony of one 'sandaled' passenger sitting in the middle of the first car. He saw the front start collapsing. He ran. Whereby the floor and carpeting picked him up that placed him in the back of the car up in the ceiling. He was unhurt. And the guy sitting across from him who did not run also walked away unhurt. Another curiosity.

The investigation is done. Reason why this crash happened was even traced to oscillations from a push pull amplifier. Feedback that occurred only when installers increased output power. And explains why this problem also caused bobbing on other adjacent tracks five days before nine people were murdered.

So much information that I may have missed it: why rail 'bluing' is only in the first half of that crash.

BTW, also interesting is a train operator who literally disobeyed Central command (OCC) instructions to stop in Silver Springs. Who proceeded to the next station anyway. Attitude among Metro employees was (apparently) that bad. The train that nearly harmed investigators because it passed at full speed instead of a required 10 MPH - and was reported by the Washington Post. Both he and his supervisor were reprimanded for being that irresponsible. But it does not say what happened to them - how they were punished or retrained. Or if they were only doing what management encouraged.

Information in that safety investigation implies repeatedly why 40% of all rail fatalities occur on the Metro system. We should be discussing murder charges in Metro management.

[tw]

Documented are safety problems (bobbing) that existed for years without resolution. That a repair crew even left the offending signals bobbing five days before the fatal crash. Another report demonstrates why these are not accidents. Why 85% of all problems are directly traceable to top management. From the Washington Post of 5 Mar 2010:

FTA delivers scathing report on safety of D.C. Metro
The sternly worded report ... was the first in-depth look at Metro's safety program ... It revealed deep-rooted deficiencies at the transit agency and its independent oversight committee, highlighting vulnerabilities in the systems that are supposed to safeguard passengers and workers, he said.

The report excoriates Metro executives and the independent safety monitors at the Tri-State Oversight Committee, citing failures that include:

Metro has no process to ensure that safety problems are identified in a timely fashion. Top leaders don't receive regular reports about safety issues. The safety office has been marginalized within the agency, lacks access to key data about subway operations and has been left out of decision-making.

As a result of those problems, the report says, the safety office has allowed known hazards to remain uncorrected for years.

That's sufficient for Daily News (tabloid) readers. For others who learn the whys before knowing anything, useful facts are buried at the end of the article:

Federal auditors found systematic failings in the way Metro identifies and prevents safety problems. Metro has no process or "single point of responsibility" to guarantee that hazards are spotted quickly. The agency has no database for long-term tracking of safety issues. When auditors asked for a list of the "top 10" safety concerns, they were told that Metro had no such list.

Top Metro executives also make critical decisions about operations without analyzing potential hazards, auditors found. Nor is there effective coordination among key operating departments -- such as rail operations, track maintenance and engineering -- to find and manage maintenance-related safety issues, Rogoff said.

The FTA report said Metro's safety office "is not 'plugged-in' to critical conversations, decision-making meetings and reporting systems that provide information on hazards and potential safety concerns throughout the agency." Critical documents, reports and decisions are not shared with the safety office, the report says.

Auditors also said that since 2007, when Catoe took over, four people have been in charge of safety. The department has been reorganized six times in five years, losing personnel and technical expertise. One-fourth of the 41 staff positions allocated to safety remain vacant. Safety, the report said, "has insufficient resources to keep up with a growing backlog of accident and incident investigations."

We see this when business school graduates do what is taught in those schools. "A good manager can manage any business." We should be discussing murder charges. The business school mentality – it was only an accident.

View back 6 months to earlier posts. How long ago were the symptoms screaming 'failure at the highest levels of management'? How criminally negligent are those failures now that facts have arrived? It is classic business school attitude - there is plenty of blame to go around. Nonsense. We should be talking murder charges. It was not an accident.

[xoxoxoBruce]

If it's not intentional, it's an accident. Even preventable accidents, are accidents.

[tw]

Originally Posted by xoxoxoBruce

If it's not intentional, it's an accident. Even preventable accidents, are accidents.

Which works with business school concepts. And is contrary to the well proven concepts taught by W E Deming. This is no accident. Management had to intentionally pervert all well understood and required safety functions to make death possible. Alienate safety functions which, on spread sheets, means reduced costs.

Those technicians ended their shift reporting that the interlock was bobbing - on both rails. For five days, nobody did anything. No management system even existed to detect what the employees knew. That was an accident? Only if you are from a business school where failure is an option. Where human life is measured in dollars. And where technical knowledge of the business is something dirty to avoid.

They did not even have a list of their top ten greatest safety problems. Typical of management that is only concerned with spread sheets. And that is trained to call it an accident so that Deming's concepts can be ignored.

It was no accident. Deaths directly traceable to overt and intentional negligence at the highest levels of Metro management. Quoted reports make that obvious. They did not do their jobs – for years. They even subverted safety functions - for years. So people died - uselessly.

We are waiting for their defense: there is plenty of blame to go around. Blame others. Maybe we should blame the victims for their own death?