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Feds: Fatal trolley crash could have been avoided
By adamg on Tue, 07/14/2009 - 9:52am
National Transportation Safety Board investigators said this morning that either of two possible fixes could have kept a Green Line operator from plowing her train into another train in Newton last May - while one board member suggested the federal government find a way to withhold money from the MBTA until it fixes its "failure in the safety net for transit riders."
Also, investigators said trolley drivers were not reporting broken signals to the department responsible for fixing them. At a hearing in Washington this morning, Board member Robert Sumwalt said he was "incredulous" at "the lack of a safety culture of this organization."
Investigators say they will urge the MBTA to install a "positive train control system" on the Green Line. This sort of system - already in place on the other three subway lines, either sounds an increasingly loud alarm when the driver drives through a red light or stops the train automatically.
The T recently announced it would test a radar-like alerting system on the Mattapan Line, which uses ancient, reconditioned Green Line trolleys.
NTSB acting Chairman Mark Rosenker blasted the T for not installing such a system earlier: "If technology exists, and it exists on the other lines, why would the Green Line not have everything possible that is going to prevent the accidents from happening? I don't understand that, as an operator, I just don't."
Also, investigators said that requiring MBTA drivers to alert their "trailing" operators (the ones who sit in the second car) of any red signals, the trailing operators could question the drivers when they proceed through the signals. In the Newton crash, the NTSB says driver Terese Edmonds blew through a red light at 38 mph and ran right into the back of another trolley that had itself just stopped for a red light and was just beginning to get moving again.
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Comments
From the no shiat
From the no shiat department....
Fire Danny Boy. This is his failure to take his job seriously. His failure to turn things around at the MBTA. His failure to deal with the unions, and His failure to be proactive, instead of reactionary.
It will be interesting to see if the NTSB final report
has anything to say about the MBTA's practice of using permanent stop signals for speed control.
I would assume it could be easy...
to simply have some sort of GPS system that has a map for each T driver. This map could have all the other trains on the map and which tracks they are on.
I could be way behind on this as I havent paid too much attention to these T discussions.
Problem
Satellites = in the sky
MBTA trains = underground, much of the time
yea....I thought about that...
but there has to be something since every train is actually attached to something.
WiFi or radio positions
WiFi or radio positions systems.
http://www2.computer.org/portal/web/csdl/doi/10.1109/MDM.2009.57
Problem is cost, most likely to union bitching and picking a political hack contractor. Still, there's no reason they should even allow the T to operate these days without directly knowing where each train is in the system.
Currently, this is done by calling the crowded dispatch room, and dispatch frequently can't get a accurate answer, gets ignored, or gets false info.
Clarification?
If I understand correctly, the front train that was hit from behind stopped for a signal that was in "failsafe" (showing a red light because the circuit was disrupted due to faulty/unreported maintenance need, even though no train was in front of it).
The second train that hit the first train went through a red light which was functioning properly because the first train was on the track ahead of it (potentially because the operator had been lulled into seeing faulty failsafe reds in that section of track).
So, my questions are: What the hell do we have these guys shutting down the entire system at 1 AM for if they're not going to find these sorts of faulty bonds between rails? Why weren't operators reporting the faulty signal to HQ??
Trolley crash
From what I heard on the radio, the following train went through a red light that was stuck on red.
What it sounds like to me is: the light was stuck on red for a month or however long, nobody ever fixed it, so they all got used to driving through it.
Maybe I got it confused
I *thought* they said only one of the two signal circuits was broken and I got lost in the discussion between signal 64 and 66 (I think those numbers are right) because I was also doing my job at the same time that I was listening to the testimony and didn't have a chance to examine the slide diagramming the scene.
Just like how most operators often routinely blow through
all the other Green Line signals that are permanently kept at red to force the trains to always stop, even when the track ahead is perfectly clear.
LOL @ Mr. Rosenker
"Why are there systems (positive control) that can prevent loss of life and injury that could be overlaid that are not implemented? As an operator, I would think that we would do EVERYTHING possible..."
LOLBudget.
but....
Like a PTC system that just killed 9 people in DC???
That's quite the limb you're out on there, NTSB
Seriously? She died because she was fat? It looks like someone's logic train just blew through a failsafe...
Operator was fat. Fat people have sleep apnea more often than fit people. Sleep apnea can cause fatigue. Fatigue causes micro-sleep. She must have gone into micro-sleep after leaving Waban station and therefore missed the signal while asleep at the wheel and crashed the train.
Guh, whaaa'? So, now the MBTA has to talk about sleep disorders with their operators? LOL, sigh...
The MBTA should talk about sleep disorders
Ever done shift work Kaz? Split shifts?
These can seriously screw up sleep patterns. Some operators work from early to mid-morning, and then return to work the evening rush hour. My FIL did this for years and years. It didn't seem to affect him to split his main block of sleep, but it can seriously affect others.
As for "fat", well, overweight people are more prone to sleep-apnea, but it isn't exactly confined to the overweight. My grandfather was 5'8" tall, 135 lbs, and died as a likely result of sleep apnea while taking a mid-day nap during a day of cutting wood.
Split Shifts
The main part of their sleep should be at night. The trains stop around midnite even if she were working until midnite, that's still plenty of time to get some sleep. Stop making exscuses for everybody. There is no failsafe system on my truck and I seem to get where I'm going without falling asleep. If you can't pay attention to what your doing don't blame the job, the system or politicians find someone who can do it without falling asleep or talking on the phone or texting.
Sleep Anonymous
Trains leave park a bit after midnight, and actually don't stop until 1am. Then it takes time to park them, and get home to bed.
So, if a driver is in bed at 1:45 am ... and trains start at 5 am ... that's enough sleep? (not that anybody actually works that schedule - just calling out the mathmatical and biological incoherence here).
Excuses? No. Explanations of why the T needs an an awareness program? Yes. It doesn't really matter if she was split shift worker or not - a substantial percentage of drivers do split shifts and, thus, the T needs a program.
I don't believe anyone has
I don't believe anyone has offered evidence that this is MBTA policy.
If you can, please do. My guess is that policy, at a minimum, requires 8 hours off shift. Which begs the question, are managers following policy correctly? if not, why no disciplinary action?
Which goes right back to Dan. Fire him. We need accountability and transparency; and neither had been offered by Mr SUV.
Tired discussion
They covered all of that. She was getting appropriate amounts of available sleep time (8 hours) off the job. Her work schedule was regular and steady. She wasn't splitting or anything else.
Thats what I'm seeing. She
Thats what I'm seeing. She wasn't being overworked and her sleep / night rest is her own resposability.
A boring job that needs you attention is still a job. Truck drivers are charged for falling asleep at the wheel and causing accidents. I don't see how their companies are responsible, unless directed to pass on sleep.
Wasn't a major study linking obesity to sleep apnea discredited
in an academic mini-scandal recently? Perhaps there have been other, more conclusive and reliable studies showing the same linkage, but I specifically remember a Globe story about a local researcher studying this who fudged the data and received some kind of slap on the wrist. I'll try to find the link- it was interesting.
Here's that academic fraud link
Dr. Robert Fogel falsified data in sleep apnea study
Not just the budget
Massachusetts has some truly spectacularly poor examples of safety systems culture. It starts with having far too many appointed positions which should be professional positions, and because the needs of political machines are put ahead of best practices for working systems for serving the public. This extends to situations like having firefighters inspect trucks every once in a while - it has to stay with your friends, not with professionals.
These failing systems are NOT soley faulty due to lack of funding - in fact, MA government seems to have been defunded in part due to being faulty, at least from a taxpayer service perspective. The problems have been around for a very very very very long time, funding or no.
Many problems also stem from an underlying culture in the region of "kill the messenger, ignore the problem". It is a culture where a person who identifies and raises awareness of problems is systematically dog-piled and attacked as "not being a team player" and turned into an alternative problem that must be obliterated. If this happens to civilians in civic life in such shocking fashion, it is likely enshrined in public organizations.
It doesn't take money to have a signal fault reporting system for drivers. It takes money to do maintenance, but it takes more money to NOT do maintenance.
Finally, until and unless MA learns the bitterly hard lessons of EPIC FAIL that the state of Washington did and changes the constitution to allow dedicated funding streams and multiple year appropriations, the problems with the Authorities and the problems with agencies not doing maintenance because it comes out of their budget (falls on floor laughing) will not end. Unless the "fifty levels of appointed friends" crap that necessitates the killing of messengers rather than the solving of problems is modernized, there will continue to be agencies that exist for primarily political ends and self service and insularity, rather than excellence in performance of public service.
well swirly....
...when you're right, you're right:
This attitude pervades the business, non-profit, public, and civic cultures of Greater Boston, and all too often it fuels screw-ups, mediocrity, corruption, petty and not so petty retaliation, and a monstrous sameness of worldview.
Maybe everywhere
This phenomenon is what I think the TV show "The Wire" was mainly about: institutional stupidity and self-interest interfering with the legitmate, socially beneficial goals of institutions. Underling makes suggestion, asks legitimate questions; underling is identified as a troublemaker, maybe targeted for discipline or removal. I guess it's merely human nature: few people care more about doing their job well than they do about merely keeping their job, feeding their own family, etc. Suggestions for improvement, especially from below, carry an implicit criticism of superiors, a potential "loss of face", and thus represent a threat that must be suppressed instead of a resource that should be drawn upon.
I love "The Wire"!
Dan, I'm not sure if I agree that this dynamic is everywhere. Or maybe I see it being deeper and more pervasive in Boston than in many places.
In any event, your mention of "The Wire" nails it! Earlier this year I was telling a colleague that I love The Wire in part because it helps me understand Boston and its institutions. A few months ago I wrote about The Wire on my blog: http://newworkplace.wordpress.com/2009/02/02/work-...
How many people were killed
How many people were killed on the T in the last 10 years?
How many people in cars were killed in the last 10 weeks?
Id place a pretty large bet on the latter being much higher.
Where are federally mandated stop signals on highways?
Why can cars, driven by inexperienced and untrained civilians speed at 80MPH at 2 second headways, while our subways are limited to 59MPH and 90 second headways+ even though the drivers have to go through an extensive screening and training process?
Why isnt there a congressional hearing every week for the hundreds killed by cars?
Why dont cars have failsafes that make them stop if they get to close to other vehicles?
Who is taking pictures of drivers using cell phones and sending it to the highway police?
Photos of destruction
A couple of the NTSB's documents show the massive impact on cars 3667 (PDF) (the "striking" trolley, operated by Edmonds) and 3703 (PDF), the "struck" trolley. Grisly irony in the display ads.