Amtrak safety culture issues or just individual irresponsibility?

[jis]

http://www.philly.com/philly/business/safety-amtrak-failures-worker.html?nlid=10729203

 

[TiBike]

We're all responsible for our own actions. Culture is no excuse for doing the wrong thing. That said, the problem starts with the workplace culture at Amtrak, at least judging by the inspector general's last report:

https://www.amtrakoig.gov/sites/default/files/reports/OIG-SP-2017-009.pdf

 

[Thirdrail7]

I think an equally valid question is it individual irresponsibility coupled with an Amtrak Safety Culture issue OR an Industry Culture issue? If Amtrak and.or the industry has an issue, how can they really teach an individual safety? Chances are, they don't know it to teach.

 

[jis]

Good point Thirdrail! Hard to fit all that in a thread title though.

 

[Karl1459]

I have to say this is a culture issue that is shared by both management and labor. When this first happened the Union rep jumped up and viciously pointed fingers at management. Management pointed fingers at the guys that were killed. Rules and principals were not followed so everyone including the regulators is on board to do what they always do... make another rule. So we have the "Joe Rule" (Joe screwed up so we make another rule), the "Mark Rule" (Mark screwed up...), etc. And all these rules end up in a "HUB" (Huge Useless Binder) which is too big and complex so is mostly ignored until the next time someone is hurt or killed, and then only used to tell the "guilty" "you shouda". The above is a synopsis of a lecture from a Fire Department officer leadership seminar.

To change it the finger pointing can only be at yourself. One of the best attitudes I have seen is the St Louis Fire Chief who declined to fire a couple of people who violated rules which ended up with two firefighter deaths. He wanted those people to stay to be available to tell other employees and new employees that on that day they killed two brothers! Amtrak is looking to discipline the foreman that had gone off shift. Wrong! Amtrak and that foreman need to accept what happened and the foreman needs to have the opportunity to explain to every Amtrak employee his link in the chain that killed those workers. If the foreman keeps violating rules then fire him then. But enable the people working below him to assure themselves the rules are followed both to management and the Union, and both the Union and management need to agree not to condone unsafe practices or workers. At the same time management needs to be familiar with the time it takes to be safe and to be responsible for allowing that time on any and every job.

Sorry for the rant. A safety culture is not easy. 35 years ago our Fire Department decided something as simple as wearing seat belts was important. Maybe 10 years ago we got the culture to 100% wearing, requiring both "lead by example" and peer pressure. And many firefighters across the country are still killed or injured in crashes where they are not wearing seat belts. Yes, firefighters.

 

[railiner]

I don't know enough of the facts of the accident in question, to formulate an opinion of who was to blame....individual's or as the defendant claimed poor safety culture. I will say that on most jobs, if everybody always "went by the book", it would certainly cause havoc...as is sometimes evident when "job action's" call for "safety slowdowns". People with a lot of experience, have learned to take certain shortcuts, to do things more efficiently, with a calculated risk that seems reasonable. To be fair, the victims of the accident I'm certain would rather have had it done with "safety first", always....

One thing I have noticed on the New York subways....for many years, they conducted track and infrastructure maintenance, while still maintaining a certain level of service. It seemed almost like a point of pride, that the "trains always get thru". However, in recent past, the practice has become more and more to shut the whole line down, and "fast-track" the maintenance, primarily for worker's safety. Not sure if that practice would be applicable for Amtrak to emulate...

 

[jis]

Yeah, the devil often is in the details.

 

[PRR 60]

I don't know enough of the facts of the accident in question, to formulate an opinion of who was to blame....individual's or as the defendant claimed poor safety culture. I will say that on most jobs, if everybody always "went by the book", it would certainly cause havoc...as is sometimes evident when "job action's" call for "safety slowdowns". People with a lot of experience, have learned to take certain shortcuts, to do things more efficiently, with a calculated risk that seems reasonable. To be fair, the victims of the accident I'm certain would rather have had it done with "safety first", always....

One thing I have noticed on the New York subways....for many years, they conducted track and infrastructure maintenance, while still maintaining a certain level of service. It seemed almost like a point of pride, that the "trains always get thru". However, in recent past, the practice has become more and more to shut the whole line down, and "fast-track" the maintenance, primarily for worker's safety. Not sure if that practice would be applicable for Amtrak to emulate...

In a business like railroading, and in particular, high-speed railroading, you do it exactly by the book, or this eventually will be the result. My job involved work not unlike this - high voltage electric transmission. There was no such thing as shortcuts to get the job done faster. Every job had a written set of steps that had to be taken and confirmed before anyone could violate the minimum safety clearance zone to work a line. All oral communications was "three-part." When the work was completed, a similar checklist of steps was preformed and confirmed before the dispatcher would close the breakers and energize the line. Who enforced this? The workers themselves. They knew how dangerous the work was, and they made sure that every "i" was dotted, and every "t" was crossed before reaching out and touching a conductor that, just minutes before, had been energized to 500,000 volts. The experienced guys: the hard-talking, hard-living vets of high line work were just as safety conscious as the rookies, if not more so. They knew, and maybe had seen firsthand, the result of electric shock burn. Like the peach basket removal of what once was a person after getting hit by a high-speed train, it is not a sight you soon forget.

If I came out to a job site, as I often did, the foreman would greet me and run down what they were doing, what blocks and tags were in place, any specific safety measures that applied to me, and ensured that I was wearing proper PPE. I would sign on to the job briefing sheet, and then and only then could I approach the work. Sure, they all knew that I knew the job - it was likely a job I designed. They also knew me because I probably sat and had coffee with them just hours earlier. That did not matter. It was the way work was performed to ensure safety, and that was that.

This guy allowed people to work a track without the last line of defense, signal shunts, being in place. That is like working a power line without working grounds at the work site. He re-opened a track for operation without ensuring that workers were off the track and would stay off the track. He left the jobsite without briefing the oncoming person-in-charge of the status of the track. If Amtrak's culture winked at that kind of work practice, then heads should roll up the chain of command. But, the bottom line is - he did it. Two people died as a result. If all that happens is that he loses his job, he should consider himself very lucky.

 

[Thirdrail7]

In a business like railroading, and in particular, high-speed railroading, you do it exactly by the book, or this eventually will be the result.

Except the "book" is subject to interpretation and that is why I mentioned this is more than a single company. It is an industry issue that often stems from regulations that are written so broadly, that things can be taken anyway. It varies by person. It varies by department. it varies by person in department. It varies by railroad.

If you did it "by the book," it would actually be impossible to couple two cars together without technically violating restricted speed.

This guy allowed people to work a track without the last line of defense, signal shunts, being in place. That is like working a power line without working grounds at the work site. He re-opened a track for operation without ensuring that workers were off the track and would stay off the track. He left the jobsite without briefing the oncoming person-in-charge of the status of the track. If Amtrak's culture winked at that kind of work practice, then heads should roll up the chain of command. But, the bottom line is - he did it. Two people died as a result. If all that happens is that he loses his job, he should consider himself very lucky.

Indeed but if you read the report, it noted that Amtrak didn't even have enough shunts to possibly cover that rule. If that is the case and it became "standard operating procedure" to work without them since they are "supplementary items (kind of like ACSES is considered a supplementary device) and largely unavailable, then it is indeed WAY above his level. Should he be culpable for following the "standard operating procedure" that was condoned by the company?

 

[jis]

While all of these peripheral factors could have minimized or eliminated the consequences of the original failure, in my possibly naive, outsiders way of thinking, the proximate and root cause was the failure to protect people on the track by the outgoing supervisor (Robinson). For him to claim that he did it because that is the tradition IMHO is a bit specious. Maybe he needed to break the tradition and actually do a few actions needed during handover of shift. So I am with PRR on this.

Is it the case that all the rules make sense together? Maybe not. But someone who does not have enough common sense to realize what the consequences of breaking the ones that he chose to break, is a problem, as illustrated. The least he can do is own up to his responsibility, the ones that he failed to fulfill.

Again, just my view as an outsider.