Amtrak Train Wreck Train #188

[kentuckysouthernrwy]

Heard news report this evening that the engIneer has been faulted for being distracted by the conversation on the radio concerning other train being rocked....

[Amboy Secondary]

OK, so it takes the Dog and Pony Show that is the NTSB a whole year to provide a lame excuse that the Engineer was "distracted" by radio conversation? Oh, yeah, another plug for PTC as a cure all for all railroad accidents.

The cause of the accident, was evident seconds after it happened. The Engineer, or Operator if you prefer, failed to control the movement of his train, resulting in the trains operation in excess of maximum allowable speed for the restricted curve, resulting in the derailment and damage to train # 188.

The absence of PTC at the time of the accident does not absolve the Engineer from his failure to keep is train under control.

The presence of radio chatter on the appropriate railroad frequency, does not absolve the Engineer from his failure to keep is train under control.

The engineer, is supposed to know where he is at all times, and is supposed to operate his train in accordance with all current rules and practices. If for any reason he cannot do this, he is to bring his train to a safe stop, (not a sudden or abrupt stop far from the rails he is supposed to be on.

After one year, we do not know any more than we knew at the time of the accident.

What we do know, is that the NTSB is useless.

[canrailfan]

An engineer distracted by a radio conversation doesn't seem a very likely cause. Engineers experience this type of distraction every day without causing derailments. Unless the engineer was participating in the conversation (he wasn't apparently) I can't believe this is the answer. He has testified he can't remember approaching the curve, this would suggest a loss of consciousness, not simply being distracted.

I still wonder if the engineer may have had an absence seizure (https://en.wikipedia.org/wiki/Absence_seizure) caused by an episode of photosensitive epilepsy (https://en.wikipedia.org/wiki/Photosensitive_epilepsy). An engineer driving a train at night under the catenary may well experience the type of flashing that triggers an episode of PE. The engineer may be an individual who is susceptible to this. It would be nice to know if the NTSB investigated this possibility and perhaps had the engineer tested to determine if this may be a possible cause.

I bring this up because a close friend was involved in a serious car crash some years ago, caused by the other driver experiencing an episode of PE due to the headlights of approaching cars flashing between the posts of the highway median divider. There were no indications the other driver was suffering from fatigue, he had no history of seizures but stated later that he didn't remember the moments leading up to the crash. He was tested and found to be susceptible to PE. He was then restricted to driving in daylight hours only.

I'm not making an excuse for the engineer but there is a difference between simply being distracted and being unconscious due to a medical condition. It would be useful if the NTSB took the time to determine which is the case. Perhaps all engineers of high speed trains in the corridor need to be evaluated for their susceptibility to PE.

[riogrande]

wjli25 - agree'd pretty much with everything. I heard the report on the way into work this morning. It seems if the engineer was distracted, and it resulted in the crash, then he's to blame. It sounds like no excuse but rather blame squarely placed. Not sure what the punishment or actions should be.

[mlehman]

Blame. Take away the B and you have exactly what that's really useful here?

I think the NTSB's response is a measured one that seems to make some unhappy that they did not use the B-word. Saying the radio traffic was a distraction and contributing factor seems to me accurate and supported by the facts. Trying to hang the whole mess on one person like it was just another calm day at the office seems rather beyond that, as well as beyond how the NTSB assessed things.

Maybe it's buried in the fine print of what I'm certain is a voluminous report, but I'd still like to know what caused the windshield damage seen here...



The loco does not appear to have rolled and ended up upright. There the possibility that it struck something after leaving the track, though. But it still suggests something more than calm day at the office or even a hectic day for an engineer under normal circumstances, which we know Mr. Bostian had already experienced. In fact, it suggests a situation where I'm not sure any of us can say with certainty how we would have reacted if similarly situated and things started happening quickly and unexpectedly.

Yes, it appears as has been suspected that the loss of situational awareness was a major factor, if not the primary factor in this accident. Mr. Bostian was at the controls, trained and qualified. And it appears his timing to brake for the upcoming curve was off the mark. Was it due to inattention or lack of care? That does not seem to be the case. Confusion? Distraction? Possibly, as that seems to fit what is known much better.

It's easy to say that Bostian should have done things differently. But it's much more difficult to say that if it had been someone else things would be any different, as there seem to have been things going on that weren't within his control, which he had to react to precisely and quickly to avoid catastrophe. He failed in that. I'm not sure that others can say they would have done it differently if they were there instead.

If humans were perfect, there would be no need for PTC. But long before this accident we knew that humans are not perfect. Systems that depend on almost solely on perfect and precise reaction by humans to prevent failure are already suspect, even if they haven't failed yet. PTC itself is likely not perfect, considering that humans are involved, as we were recently reminded in the subsequent Amtrak crash on the NEC with a hy-rail tractor where PTC was in effect. But the answer is clearly not, "Let's just count on holding humans 'accountable'..." as we know that doesn't work to either prevent or remediate accidents.

[canrailfan]

One discussion I remember reading back nearer the time of the crash suggested the windshield damage was possibly caused by an insulator or catenary bracket as the wire was being brought down by the derailing train.

I don't know if it was ever mentioned in later reports.

[kentuckysouthernrwy]

Back in my long career in Law Enforcement we had a covers it all charge for the inexplicable accident, "Failed To Use Due Care and Caution" That is what it appears they've thrown out, at least for public consumption. I'm sure that the report, in spite of conclusions here to the contrary, has looked into every conceivable cause including as much physical examination of the fitness of the engineer as allowed by the union rep and attorneys looking after his rights as well as a thorough examination of the locomotive, signaling system and physical plant of the railroad, weather, light conditions and probably the phase of the moon and karma readings of the engineer.

As in most aviation accidents the operator of the vehicle is assumed to be at fault until the investigation finds something else that can't be ruled out. Just because we haven't read it in the media doesn't mean that it hasn't been done. Media releases are notorious for providing as little information as possible to keep the body politic at bay.

[Amboy Secondary]

Mike wrote: "Yes, it appears as has been suspected that the loss of situational awareness was a major factor, if not the primary factor in this accident. Mr. Bostian was at the controls, trained and qualified. And it appears his timing to brake for the upcoming curve was off the mark. Was it due to inattention or lack of care? That does not seem to be the case. Confusion? Distraction? Possibly, as that seems to fit what is known much better."

My opinion, from the standpoint of an experienced, qualified Locomotive Engineer who was qualified to run trains on the NEC at the location of the accident, I would have to agree that there was a loss of situational awareness just prior to the incident. What caused that, I don't know. However, I do not buy the explanation that the Mr. Bostian was somehow distracted by radio traffic. Unless Mr Bostian at some point publicly discloses what caused him to lose situational awareness, we may never know.

My opinion, from the standpoint of an experienced Engine Service Manager and Instructor, and a qualified and experienced Railroad Accident Investigator, the cause was clear and known immediately. Train 188 operated at an excessive speed that caused the train to leave the rails and come to rest some distance from the Amtrak Right of way.

The NTSB Report arrived on schedule one year after the event, and did not reveal anything that wasn't known shortly after the incident. There was no debate as to the cause. The accident was caused by the train being operated at excessive speed.

Mr. Bostian will most likely never work on Amtrak again, He may never run a locomotive or train again. There is no evidence he did anything of a criminal nature, however he for some reason violated numerous rules and regulations established to prevent such occurrences. He was living his dream, he had a reputation for doing a "good" job, not the kind of person who took chances or took unnecessary risk. Something happened that evening, to change all of that. He screwed up. He made a mistake, a costly mistake. Something he will have to live with for the remainder of his life. Be kind, he wasn't the first to mess up and won't be the last.

Unlike other recent occurrences, there was no mention of fatigue, distraction due to cell phone use of texting, and no impairment due to the use of substances or alcohol. The guy was clean, and in general good health. There were no known (recorded) mechanical faults, only the almost routine stoning incidents so common in that part of Philadelphia. He had been exposed to radio traffic since he left Washington. He started accelerating at about the point he should have began braking for the restriction. WHY? That, my friends is the question that was left unanswered.

[mlehman]

My concern with the emphasis on placing blame is that it focuses on the individual as the problem, when the problem appears to be systemic. One can say that the NTSB didn't come up with anything new, but it's also the case that they have previously identified the issue as systemic. From the closing statement...

I stated at the outset of this meeting that this derailment would never have occurred had PTC been active on the Frankford Junction Curve. The dozens of lives lost in PTC-preventable tragedies since 2008 are mute but powerful testament to the importance of finishing the job.

Humans are human, therefore fallible, whatever the reason...

We searched for any involvement of drugs, alcohol, or fatigue, and found none. We looked at the weather, the locomotive, and the track, and determined that this was a good train on good track, with an engineer who was fit for duty, not fatigued, not impaired by drugs or alcohol, and not distracted by a personal electronic device.

But we have long known that even in the absence of such factors, human beings are fallible, making a technological backstop, such as PTC, a necessity.

If we're going to hold Bostian responsible, then we need to at least equally hold those responsible who've needlessly drug their feet on implementing PTC, who failed to fund it in a timely manner, who continue to operate trains at speeds where reaction times cannot overcome the need to react at speed to a host of potential problems, selling a service as safe when these limits and deficiencies are well known. That may sound like an indictment of Amtrak, but they have for the most part pushed for these improvements, it's Congress who thinks they can keep kicking the problem down the road when there's really nothing in place to keep this from happening again until PTC is in place along the full NEC. People died because some folks think keeping Amtrak on a shoestring budget is a political goal that serves their interests. It should be clear that this attitude, this studious neglect, fails to serve the public interest.

[mlehman]

May 17, 2016 12:04:20 GMT -8 canrailfan said:

One discussion I remember reading back nearer the time of the crash suggested the windshield damage was possibly caused by an insulator or catenary bracket as the wire was being brought down by the derailing train.

I don't know if it was ever mentioned in later reports.

Yeah, I recall that, but would think by now they could confirm whether or not all the breakage came about after the loco left the rails. Certainly, if any of it occurred prior to the accident due to being rocked, it could certainly suggest an explanation for distraction that is somewhat more concrete than inattention due to concern over the radio chatter.

[kentuckysouthernrwy]

Mike, ultimately it rests with the man at the controls of the locomotive. He screwed up, wrecked the train. Trains have been running the NEC for years without PTC and not wrecked. To infer that the lack of PTC somehow alleviates some responsibility from the engineer is charitable but not based in reality. From things I've read, I certainly wouldn't be so charitable to the current leadership, loosely used term, and their stewardship of the whole Amtrak system.

[fr8kar]

I still can't understand why it's okay to have only one person on the head end of passenger trains. Absent PTC, which doesn't always work by the way (cut out, defects, locomotive not equipped, etc.), another experienced, qualified person on the head end with the engineer could have prevented this accident along with many other engineer-only accidents.

A conductor somewhere on the train other than the head end isn't enough. Few are qualified as engineers so they don't have the same level of familiarity with the territory or experience to know when something is amiss. All kinds of things can go wrong: you could drop your warrants/work orders, get something in your eye, get an insect bite, have sudden stomach discomfort, the possibilities are endless. There could be a serious health condition that could delay the engineer's reaction like choking or a heart attack.

On the trains I operate things don't happen very quickly. The alerter can stop the train quickly (+/- 30 seconds) if it's unattended. If the delay on the alerter on passenger locomotives is anything like those on freight locomotives I can imagine a lot can happen before the alerter kicks the train into a penalty since the engines are powerful and the trains are light and designed to accelerate.

I have another person with me on the head end (for now) who can double check where exactly we are, where that verbal speed restriction starts, who can ask why we're still accelerating downhill toward the form B limits and who can tell me to stop or do it for me if something goes wrong. I have that other crew member with me when I'm transporting crude oil, grain or even empty intermodal flatcars. How are any of these cargoes more valuable than human passengers?

Some trucking operations use team drivers, sailing vessels have more than one person on the bridge, airplanes have a captain and a first officer, both of whom are qualified pilots. Why do we allow our passenger trains to be controlled by a single, fallible person? No matter how good you are, you will make a mistake at some point. Hopefully it's minor and no lives hang in the balance. How many more of these wrecks must there be before we can rely on something better than hopefully?

[mlehman]

May 18, 2016 6:08:41 GMT -8 kentuckysouthernrwy said:

Mike, ultimately it rests with the man at the controls of the locomotive. He screwed up, wrecked the train. Trains have been running the NEC for years without PTC and not wrecked. To infer that the lack of PTC somehow alleviates some responsibility from the engineer is charitable but not based in reality. From things I've read, I certainly wouldn't be so charitable to the current leadership, loosely used term, and their stewardship of the whole Amtrak system.

The problem is that placing all the responsibility on the engineer does exactly NOTHING to prevent this from occurring again. It does satisfy certain atavistic desires to blame someone, but does nothing for safety. To me, that doesn't deny whatever responsibility Bostian had, it just notes he's far from the only one whose actions or inactions led to the accident.

One may quibble with Amtrak's leadership in a number of areas, but I really doubt any of them countenance neglecting safety...unlike the politicians who see nothing wrong with ignoring the prospects of future accidents that may occur before they finally get around to funding critical safety improvements.

[Amboy Secondary]

May 18, 2016 7:12:18 GMT -8 mlehman said:

May 18, 2016 6:08:41 GMT -8 kentuckysouthernrwy said:

Mike, ultimately it rests with the man at the controls of the locomotive. He screwed up, wrecked the train. Trains have been running the NEC for years without PTC and not wrecked. To infer that the lack of PTC somehow alleviates some responsibility from the engineer is charitable but not based in reality. From things I've read, I certainly wouldn't be so charitable to the current leadership, loosely used term, and their stewardship of the whole Amtrak system.

The problem is that placing all the responsibility on the engineer does exactly NOTHING to prevent this from occurring again. It does satisfy certain atavistic desires to blame someone, but does nothing for safety. To me, that doesn't deny whatever responsibility Bostian had, it just notes he's far from the only one whose actions or inactions led to the accident.

One may quibble with Amtrak's leadership in a number of areas, but I really doubt any of them countenance neglecting safety...unlike the politicians who see nothing wrong with ignoring the prospects of future accidents that may occur before they finally get around to funding critical safety improvements.

I think Mike already mentioned this, but PTC is not a panacea. The recent wreck at Chester, PA was not prevented by PTC, for instance. PTC (ASCES is the System used by Amtrak), is another tool to enhance safety, but it's just a tool. I don't know what, if any, extenuating circumstances were involved that night on and around #188, nor do I know about Mr. Bostian's thinking at precisely that time, that is what caused him to set the throttle to accelerate, when he should have been breaking, but the buck stops with the engineer at the controls of the train.

Amtrak spends a lot of money on training its employees. I'm not sure if they get their moneys worth. I'm not sure how to improve over what they do either. Mr Boatian, at the same stage of his career, was significantly better trained and educated in his profession than I was. Yet I never screwed up, at that level.

The root cause of Amtrak's problems, whether they be safety, scheduling, etc, is the Government culture that Amtrak lives in. In the minds of many at Amtrak, they are Government, and as such are wiser, more knowledgeable and more important than any other railroad. Funding, for safe operations, new equipment etc, is secondary to funding to conform with other mandates placed on them by other Government Agencies or Congress. That's why the cab signal code was not set to force a 45MPH speed at the beginning of Frankford Curve. It was more important to build ADA compliant platforms at remote locations on tri-weekly routes, or comply with state EPA cleanup, on Federal property in Delaware as part of a construction project, although Amtrak enabling legislation, never repealed, exempts Amtrak from State and Local regulation. In short, Amtrak's priorities are skewed. One "insider" report from my network of former co-workers, indicated that ASCES was in place at the location, but not yet put into service, because another government agency that uses the same tracks had not as yet equipped their commuter cars with ASCES compatible electronics. Rather than hold the tenant carrier to their contractual requirements, Amtrak, possibly under political pressure, elected to hold off implementation until the other agency was ready. One cannot make this stuff up. It happens all the time, although usually it doesn't backfire on Amtrak so dramatically and violently as did the incidents at Frankford and Chester.

The second man, (person), on a passenger train probably would not have made a significant impact. A second person, whether a "Fireman". trainee, Supervisor, or deadhead, may be more of a distraction. Running trains at relatively high ground speed takes concentration. The presence of another person is a distraction. Beside, single operators have long been part of Fast passenger service. MU equipment, the Metroliner, etc. There is nothing for a second person to do, but sit there. I actually preferred the solitude. so I could focus on the track ahead.

[edwardsutorik]

In "The Mainstreeter" (NPRHA magazine) Volume 32, Numbers 1 and 2, there was an extensive 38 page analysis of the Granite wreck of the North Coast Limited in 1962.

The author established the most likely cause of the accident, and the deaths of the engineer and fireman, was situational (really: locational) unawareness. They were not where they thought they were. Neither realized they were coming into a curve at too high a speed. Sound familiar?

Back then, GPS wasn't available. It is now. I wonder why it isn't in "all" locomotives. Sure, it's yer job to know where you are. It's also "yer job" on a construction site to not be behind equipment backing up. They still have those IRRITATING back up alarms.



Ed

[Amboy Secondary]

May 18, 2016 11:47:46 GMT -8 edwardsutorik said:

In "The Mainstreeter" (NPRHA magazine) Volume 32, Numbers 1 and 2, there was an extensive 38 page analysis of the Granite wreck of the North Coast Limited in 1962.

The author established the most likely cause of the accident, and the deaths of the engineer and fireman, was situational (really: locational) unawareness. They were not where they thought they were. Neither realized they were coming into a curve at too high a speed. Sound familiar?

Back then, GPS wasn't available. It is now. I wonder why it isn't in "all" locomotives. Sure, it's yer job to know where you are. It's also "yer job" on a construction site to not be behind equipment backing up. They still have those IRRITATING back up alarms.



Ed

It mat interest you to know that back in 1998, the P40s and P42s were equipped with GPS, primarily, for National Operations in Wilmington, DE to track long haul OS, without having to interact with Freight Railroad Employees. I'm pretty sure the Acela equipment, and the Hippos had it also, along with some of the diesels assigned to Work Train service. Why they never considered making that sort of equipment available to Locomotive Engineers, I don't know. Part of it was that the Engineer and Conductor are always supposed to know where they are at...Another point, Since the GPS was purchased for the Engineering Department, and extended to National Operations to track long distance trains, there was no known compelling need to equip locomotives with a display option for GPS.

Since Amtrak's inception, not one CEO, with the possible exception of Claytor, was ever an operating man. Engineer, Mechanical, Sales and Marketing, Public Administration, HR, Government Affairs, real estate, Politician...but never an operating guy (or girl). Operations - meaning actual train operation - was the last portion of the passenger operation to come under Amtrak's direct control. Therefore, operational needs are the last in the food chain.

Bottom line here, is that the cause of the derailment was excess speed. The cause of Amtrak's shortcomings is much more diverse.

[calzephyr]

May 18, 2016 13:10:40 GMT -8 Amboy Secondary said:

May 18, 2016 11:47:46 GMT -8 edwardsutorik said:

In "The Mainstreeter" (NPRHA magazine) Volume 32, Numbers 1 and 2, there was an extensive 38 page analysis of the Granite wreck of the North Coast Limited in 1962.

The author established the most likely cause of the accident, and the deaths of the engineer and fireman, was situational (really: locational) unawareness. They were not where they thought they were. Neither realized they were coming into a curve at too high a speed. Sound familiar?

Back then, GPS wasn't available. It is now. I wonder why it isn't in "all" locomotives. Sure, it's yer job to know where you are. It's also "yer job" on a construction site to not be behind equipment backing up. They still have those IRRITATING back up alarms.



Ed

It mat interest you to know that back in 1998, the P40s and P42s were equipped with GPS, primarily, for National Operations in Wilmington, DE to track long haul OS, without having to interact with Freight Railroad Employees. I'm pretty sure the Acela equipment, and the Hippos had it also, along with some of the diesels assigned to Work Train service. Why they never considered making that sort of equipment available to Locomotive Engineers, I don't know. Part of it was that the Engineer and Conductor are always supposed to know where they are at...Another point, Since the GPS was purchased for the Engineering Department, and extended to National Operations to track long distance trains, there was no known compelling need to equip locomotives with a display option for GPS.

Since Amtrak's inception, not one CEO, with the possible exception of Claytor, was ever an operating man. Engineer, Mechanical, Sales and Marketing, Public Administration, HR, Government Affairs, real estate, Politician...but never an operating guy (or girl). Operations - meaning actual train operation - was the last portion of the passenger operation to come under Amtrak's direct control. Therefore, operational needs are the last in the food chain.

Bottom line here, is that the cause of the derailment was excess speed. The cause of Amtrak's shortcomings is much more diverse.

No doubt about the speed being excess. The curve is now protected by PTC so this type of accident should not happen again. My thought is a two man crew would probably have avoided this mess since one person should have been looking out the front windshield. The engineer's job is to control the train, not listen to radio chatter or whatever he was really doing.

Larry

[Deleted]

Jun 1, 2016 6:30:51 GMT -8 calzephyr said:

No doubt about the speed being excess. The curve is now protected by PTC so this type of accident should not happen again. My thought is a two man crew would probably have avoided this mess since one person should have been looking out the front windshield. The engineer's job is to control the train, not listen to radio chatter or whatever he was really doing.

Larry

PTC is just another tool. It may reduce the total number of accidents, but it won't prevent them any more than side & rear-view cameras and sensors prevent auto accidents. Is it cost-effective? Not in the current configuration. There's only a limited amount of money out there, regardless of the source. Money for PTC could be spent on other things. Trade-offs, as always.

Two-man crews are not a panacea. They can help, but there's a cost trade-off (like everything else). The money is better spent elsewhere in most cases.

Listening to the radio is part of the engineer's job. The radio is there & on for a reason.

[edwardsutorik]

Jun 1, 2016 6:30:51 GMT -8 calzephyr said:

My thought is a two man crew would probably have avoided this mess since one person should have been looking out the front windshield.

I tend to agree. But there was a two man crew on the NCL crash.


Ed

[Brakie]

Guys,Its easy to lose your place if you make the same trips every day and that's as old as railroading. The engineer of N&W 611 missed a curve and entered at regular track speed and rolled the J into the Tug Fork the Engineer was killed.This happen in the 50s. In the 30s a PRR crew ran by the siding they was supposed to take and the result was a head-on killing all six men.

Nothing has changed they always overlook the cause to point the finger at the engineer.The real reason for those wrecks I mention was more then likely hypnotic in natural from repetition.. This happens to drivers as well that's why a traffic light or stop sign can be ignore or a curve entered at high speed by a driver that's been driving that road for years. That is according to studies by USDOT.

[roadkill]

May 17, 2016 11:09:07 GMT -8 mlehman said:

Maybe it's buried in the fine print of what I'm certain is a voluminous report, but I'd still like to know what caused the windshield damage seen here...

Ummm... the same thing that damaged the right side of the cab, perhaps??? Pretty obvious SOMETHING hit the right side of that loco to bash it up like it is...

[mlehman]

Roger,
Yeah, the viewers' left/engineer's right side does look a bit caved in and the window damage on the side close to it seems to explain that. The two starred areas near the upright wiper blade seem to be a separate issue to me, although I suppose they could have been the result of that larger impact at the corner.

[calzephyr]

Jun 9, 2016 21:47:13 GMT -8 mlehman said:

Roger,
Yeah, the viewers' left/engineer's right side does look a bit caved in and the window damage on the side close to it seems to explain that. The two starred areas near the upright wiper blade seem to be a separate issue to me, although I suppose they could have been the result of that larger impact at the corner.

The camera and recorder should show when that windshield was hit, but anytime a locomotive leaves the rail at 90 mph, there has to be a lot of ballast that is tossed in front of the loco when the plow hits the ballast!
My guess is they know a lot more than the report is saying.

Larry