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Track Workers Killed by Train

By ThinkReliability Staff

A derailment and the fatalities of two railroad workers on April 3, 2016 has led to an investigation by the National Transportation Safety Board (NTSB). In this investigation, the NTSB will address the impacts of the accident, determine what caused the accident and will provide recommendations to prevent similar accidents from recurring. While the investigation is still underway, a wealth of information related to the accident is already available to begin the analysis. We will look at what is currently known regarding the accident in a Cause Map, a visual form of root cause analysis.

The first step of the analysis is to define the problem. This includes the what, when, and where of the incident, as well as the impacts to the organizational goals. Capturing the impacts to the goals is particularly important because the recommendations that will result from the analysis aim to reduce these impacts. If we define the problem as simply a “derailment”, recommendations may be limited to those that prevent future derailments. Not only are we looking for recommendations to prevent future derailments, we are looking for recommendations to prevent all the impacted goals. In this case, that includes worker safety: 2 workers died, public safety: 37 passengers were injured, customer service: the train derailed, property: the train and some construction equipment was damaged, and labor: response and investigation are required.

The analysis is performed by beginning with the impacted goals and developing the cause-and-effect relationships that led to those impacts. Asking “why” questions can help to identify some of the cause-and-effect relationships, but there may be more than one cause that results in an effect. In this case, the worker fatalities occurred because the train struck heavy equipment and the workers were in/on/near the equipment. Both of these causes had to occur for the effect to result. The workers were on the equipment performing routine maintenance. In addition, their watch was ineffective. When capturing causes, it’s important to also include evidence, which validates the cause.

We know the watch was ineffective, because federal regulation requires a watch for incoming trains that gives at least a fifteen second warning. Fifteen seconds should have been sufficient time for the workers to exit the equipment. Because this did not happen, it follows that the watch was ineffective.

The train struck the heavy equipment because the equipment was on track 3, the train was on track 3, and the train was unable to brake in time. It’s unclear why the heavy equipment was on the track; rail safety experts say heavy equipment should never be directly on the track. The train was on track 3 because it was allowed on the track. Work crews are permitted to shut off the current to preclude passage of trains into the work zone, but they did not in this case, for reasons that are still being investigated. Additionally, the dispatcher allowed the train onto the track. Per federal regulations, when workers are on the track, train dispatchers may not allow trains on track until roadway worker gives permission. It appears that in this case the workers either failed to secure permission to work on the track (thus notifying the dispatcher of their presence) or the work notification was improperly cancelled, allowing trains to return to the track, possibly due to a miscommunication between the night and day crews. This is also still under investigation.

While inspection of the cars and maintenance records found no anomalies, the braking system is under investigation to determine whether or not it affected the train’s ability to brake. Also under investigation is the Positive Train Control (PTC), which should have emitted warnings and slowed the train automatically. However, the supplemental shunting device, which alerts the signaling system that the track is occupied, and is required by Amtrak rules, was not in place. Whether this was sufficient to prevent the PTC from stopping the train in time is also under investigation. The conductor placed the train in emergency mode 5 seconds before the collision. As the train was traveling at 106 mph (the speed limit was 110 mph in the area), this did not give adequate time to brake. There should have been a flagman to notify the train that a crew was on the track, but was not. The flagman also carries an air horn, which provides another notification to the track crew that a train is coming.

Says Ashley Halsey III, reporting in The Washington Post, “Basic rules of railroading and federal regulations should have prevented the Amtrak derailment near Philadelphia on Sunday that killed two maintenance workers.” It appears that multiple procedural requirements were not followed, but more thorough investigation is required to determine why and what can be done in the future to improve safety by preventing derailments and worker fatalities.

To view the available information in a Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Investigators Blame “Human Error” for Train Collision

By Kim Smiley

On February 9, 2016, two commuter trains collided head-on in Upper Bavaria, Germany.  Eleven people were killed and dozens were injured.  Investigators are still working to determine exactly what caused the accident and the train dispatcher is currently under investigation for involuntary manslaughter and could face up to five years in prison if convicted.

Although the investigation is still ongoing, some information has been released about what caused the crash.  The two trains collided head-on because they were both traveling on the same track toward each other in opposite directions.  Running two trains on the same track is common practice in rural regions in Germany and these two trains were scheduled to pass each other at a station with a divided track. The drivers of both trains were unaware of the other train.  The accident occurred on a bend in a wooded area so the drivers could not see the other train until it was too late to prevent the collision.

The dispatcher failed to prevent a situation where two trains were running towards each other on the same track or to inform the drivers about the potential for a collision.  Investigators have stated that the dispatcher sent an incorrect signal to one of the trains due to “human error”.  After realizing the mistake – and that a collision was imminent – the dispatcher issued emergency signals to the trains, but they were too late to prevent the accident.

All rail routes in Germany have automatic braking systems that are intended to stop a train before a collision can occur, but initial reports are that the safety system had been manually turned off by the dispatcher.  German media has reported that the system was overridden to allow the eastbound train to pass because it was running late, but this information has not been confirmed.  Black boxes from both trains have been collected and analyzed.  Technical failure of the trains and signaling equipment have been ruled out as potential causes of the accident.

The information that has been released to the media can be used to build an initial Cause Map, a visual root cause analysis, of this issue.  A Cause Map visually lays out the cause-and-effect relationships and aids in understanding the many causes that contributed to an issue. The Cause Map is built by asking “why” questions. A detailed Cause Map can aid in the development of more effective solutions.

One of the general Cause Mapping rules of thumb is that an investigation should not stop at “human error”.  Human error is too general and vague to be helpful in developing effective solutions. It is important to ask “why” the error was made and really work to understand what factors lead to the mistake.  Should the safety system be able to be manually overridden?  Is the training for dispatchers adequate?  Does there need to be a second check on decisions by dispatchers?  Should two trains traveling in opposite directions be sharing tracks?  I don’t know the answers, but these questions should be asked during the investigation.  Charging the dispatcher with involuntary manslaughter may prevent HIM from making the same mistake again, but it won’t necessarily reduce the risk of a similar accident occurring again in the future.  To really reduce risk, investigators need to dig into the details of why the error was made.

Root Cause Analysis - Incident Investigation

Passengers trapped in smoke-filled metro train

By Kim Smiley

A standard commute quickly turned into a terrifying ordeal for passengers on a metro train in Washington, DC the afternoon of January 12, 2015.  Shortly after leaving a station, the train abruptly stopped and then quickly filled with thick smoke. One passenger died as a result of the incident and 84 more were treated for injuries, predominantly smoke inhalation.

This incident can be analyzed by building a Cause Map, a visual root cause analysis.  A Cause Map visually lays out the cause-and-effect relationships to show all the causes that contributed to an issue.  The first step in the Cause Mapping process is to define the problem by filling in an Outline with the basic background information as well as documenting how the issue impacts the overall goals.  For this example, the safety goal is clearly impacted by the passenger death and injuries.  A number of other goals should also be considered such as the schedule goal which was impacted by significant metro delays.  (To view an Outline and initial Cause Map for this issue, click on “Download PDF” above.)

So why were passengers injured and killed?  Passengers were trapped on the train and it filled with smoke.  It is unclear why the train wasn’t able to back up to the nearby station once the smoke formed and investigators are working to learn more.  (Open issues can be documented on the Cause Map with a question mark to indicate that more evidence is needed.)  There are also questions about the time emergency workers took to reach the train to aid in evacuation of passengers so this is another area that will require more information to fully understand. By some account, it took 40 minutes for firefighters to reach the trapped passengers.

Initial reports are that smoke was caused by an electrical arcing event, likely from the cables supporting the high voltage third rail used to power the trains. The specifics of what caused the arc are being investigated by the National Transportation Safety Board and will be released when the investigation is concluded.  What is known is that there was significant smoke caused by the arc, but no fire.  There have also been reports of water near the rails that may have been a factor in the arcing.

Eyewitness accounts of this incident are horrifying.  People had little information and didn’t know whether there was fire nearby at first.  They were told to remain on the train and await rescue, but the rescue took some time, which surely felt longer to the scared passengers.  It won’t be clear what solutions need to be implemented to prevent similar problems in the future until the investigation is complete, but I think we can agree that metro officials need to work to ensure passenger safety going forward.

Root Cause Analysis - Incident Investigation

Freight Trains Collide Head-On in Arkansas

By Kim Smiley

On August 17, 2014, two freight trains collided head-on in Arkansas, killing two and injuring two more.  The accident resulted in a fire after alcohol spilled from a damaged rail car ignited, prompting evacuation of about 500 people from nearby homes.  The trains were carrying toxic chemicals, but none of the cars carrying the toxic chemicals are believed to have been breached during the accident.

The National Transportation Safety Board (NTSB) is currently investigating this accident, but an initial Cause Map, or visual root cause analysis, can still be built to help document and illustrate the information that is known.  One of the benefits of a Cause Map is that it can easily be expanded to incorporate information as it becomes available.  The first step of the Cause Mapping process is to fill in an Outline with the basic information for an incident.  In addition, anything that was different at the time of accident is listed.  How the incident impacts the overall goals is also documented on the bottom of the Outline.

Like many incidents, there are a number of goals that were impacted by this train collision.  The safety goal is obviously impacted by two fatalities and injuries.  The property goal is impacted because of the significant damage to the trains and freight.  The labor/time goal is impacted because of the response effort and investigation that are required as a result of the accident. Potential impacts or near misses should also be documented so the potential release of toxic chemicals is considered an impact to the environmental goal.

The second step is to perform the analysis by building the Cause Map.  To build the Cause Map, start with one impacted goal and ask “why” questions.  Each answer is added to the Cause Map.  Each impacted goal should be considered and the cause boxes should all connect at some location on the Cause Map.  Starting with the safety goal in this example, the first question would be: why were two people killed?  This occurred because there was a train collision.  The trains collided because they were traveling toward each other on the same track.  No details have been released about how the trains ended up on the same track.  The trains’ daily recorders (which provide information about the trains’ speed, braking and throttle) have been found and will be analyzed by investigators. The NTSB has stated that they will be looking into a number of factors such as the train signals and fatigue since the accident occurred late at night.

The final step in the Cause Mapping process is to develop solutions that can be implemented to reduce the risk of a similar problem recurring in the future.  Since the investigation is ongoing, talk of solutions is premature at this point.  Once more is known about the causes that contributed to this issue, the lessons that are learned can be used to develop solutions.

Root Cause Analysis - Incident Investigation

Train Derailment Kills 79 in Spain

By Kim Smiley

On July 24, 2013, a train carrying 247 people violently derailed near Santiago de Compostela Spain.  Over 130 were injured and 79 were killed as a result of the accident.  Many details are still unknown, but investigators have determined that the train was traveling about twice the posted speed over a curved section of track.

The derailment was the worst train accident Spain has suffered in 40 years.  Obviously, an investigation is underway and authorities are eager to identify what caused the accident and are working to prevent anything similar from occurring in the future. One of the ways this accident can be analyzed is by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map visually lays out the different causes that contributed to an accident in an intuitive format that shows the cause-and-effect relationships.

The Cause Mapping process begins by filling in the basic background information for an issue as well as identifying how the incident impacted the goals.  In this example, the safety goal is clearly impacted because there were fatalities and injuries.  The schedule, labor, and material goals were also impacted because of the time and resources needed to investigate and clean up the accident and the damage to the train.  The negative publicity surrounding the accident can also be considered an impact to the customer service goal because people may be hesitant to ride trains if they have concerns about safety.

So why did the train derail?  The train was going too fast to safely navigate a curved section of track.  The train was going fast because it had previously been running on track designed for high speed trains where high speeds were permitted and it didn’t slow down as it entered a section of track where the posted speed was lower.  Operator action was required to slow down the train and it appears that the operator failed to take action.   Investigators are looking to whether there was a mechanical problem of some kind that prevented the train from reducing speed, but early indication is that the operator simply failed to brake and reduce the speed of the train.

A number of factors seem to have contributed to this deadly error by an experienced train operator who was familiar with this portion of track.  European Rail Traffic Management System (ERTMS) automatically controls braking and is installed on most of the track high speed trains operate on in the region, but not on the track where the accident occurred.  The accident occurred at the first potentially dangerous curve after the transition to  track where operator action is necessary to brake the train.  Based on statements by the driver,  he missed the transition to  the track where manual braking is required and didn’t realize that the train was in danger.  It has also come to light that the train driver was on the phone with the train’s ticket inspector immediately prior to the derailment and this distraction likely played a role in the accident.  The initial investigation findings have led to the train’s driver being provisionally charged with multiple counts of homicide by professional recklessness on 28 July 2013.

Regardless of whether the driver is convicted on the charges, the automatic systems involved should be a focus of the investigation.  The safety system sent a warning to the operator about the high speed prior to the accident, but it failed to prevent the accident.  Investigators need to review the timing of the warning and determine whether it came too late.  Other automatic systems such as the ERTMS also have the ability to stop a train that is operating at unsafe speeds, which raises the question of whether the safety systems used on this portion of track are adequate since the accident happened.  Ideally, a single error by a train driver for any reason won’t result in dozens of deaths.

To view a high level Cause Map of this incident, click on “Download PDF” above.  Click here to view a video of the accident.

Root Cause Analysis - Incident Investigation

50 Presumed Dead in Canadian Train Disaster

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By ThinkReliability Staff

A tragic accident devastated the Canadian town of Lac-Mégantic, Quebec on July 6, 2013.  Much about the issue is still unknown.  When investigating an incident such as this, it can be helpful to identify what is known and information that still needs to be determined.

What is known: a 73-car train was parked in Nantes, Quebec, uphill from Lac-Mégantic.  Of the cars, 72 contained crude oil.  The train was left unattended and late the evening of July 5, 2013, a fire broke out in the locomotive.  While the fire department of Nantes was putting out the fire, they turned off the train’s main engine.  Less than two hours later, the train rolled down the track and derailed in Lac-Mégantic.  After subsequent explosions and long-burning fires, 24 people have been confirmed dead.  26 more are missing.   Much of the town and the train – and the evidence in it – is destroyed.

What is not known: The cause of the initial fire on the train is not known.  Whether or not the fire department should have explicitly notified the train engineer that the main engine had been shut off is not known.  What happened that allowed the train to roll downhill is unknown.

With this number of unknowns, it is helpful to visually lay out the cause-and-effect relationships that occurred, and what impact they had on those affected.  This can allow us to see the holes in our analysis and identify where more evidence is needed.  Once as much evidence as possible has been obtained, additional detail can be added to the cause-and-effect relationships.  Ensuring that all causes related to the incident are included will provide the largest number of solutions, allowing us to choose the most effective.  We can do all this in a Cause Map, or visual root cause analysis.

The first step in using any problem solving methodology is to determine the impact caused by the incident.  In this case, the deaths (and assumed deaths) are our most significant impact.  Also addressed should be the crude oil leakage (though much of it was likely burned off), the high potential for lawsuits, the possible impact on rail shipments, the destruction of the town and the train, and the response and cleanup efforts.  These form the initial “effects” for our cause-and-effect analysis.

Asking “Why” questions allows us to further develop the cause-and-effect relationships.  We know that for the train to roll backwards down the hill, both sets of brakes had to be ineffective.  The railway company has stated that the air brakes released because the main engine had been shutdown.  However, according to the New York Times, “since the 19th century, railways in North America have used an air-braking system that applies, rather than releases, freight car brakes as a safety measure when it loses pressure.”  This certainly makes more sense than having brakes be dependent on engine power.

The hand brakes functioned as backup brakes.  The number of cars (which, when on a hill, affects the force pulling on the train) determines the number of handbrakes required.  In this case, the engineer claims to have set 11 handbrakes, but the rail company has now stated that they no longer believe this.  No other information – or evidence that could help demonstrate what happened to either sets of brakes – has been released.

Also of concern are the style of train cars – believed to be the same that the NTSB identified in a report on a previous train accident as “subject to damage and catastrophic loss of hazardous materials”.

In a tragedy such as this one, the first priority is to save and preserve human lives in every way possible.  However, once that mission is complete, evidence-gathering to determine what happened is the next priority.  As evidence becomes available it is added directly to the Cause Map, below the cause it supports or refutes.  Additional causes are added as necessary with the goal of determining all the cause-and-effect relationships to provide the largest supply of possible solutions to choose from.

The company involved has already stated it will no longer leave trains unattended.  That should be a big help but, given the consequences of this event, other solutions should be considered as well.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Root Cause Analysis - Incident Investigation

Deadly Train Collision in Poland

By Kim Smiley

On March 4, 2012, two passenger trains collided head-on near Szczekociny, Poland killing 16 and injuring 58.  It was Poland’s deadliest train crash in 20 years.

An investigation is underway to determine what caused the deadly accident, but an initial Cause Map can be built now and more details can be added as information becomes available.  A Cause Map is a visual root cause analysis format.  The first step in the process is to determine which organizational goals were not met and in this example the obvious goal to focus on is the safety goal.

The safety goal wasn’t met because there were fatalities and injuries.  This occurred when two trains crashed because they were traveling on the same track in opposite directions.  It’s not clear exactly how the trains ended up on the same track, but it appears human error was involved since prosecutors have announced plans to charge a controller for unintentionally causing the accident.  Media reports have also stated that the routing mechanism for one of the trains was set incorrectly so that it was sent down the wrong track and into the path of the other train.  As with any investigation that leads to human error, more information will be needed about why the mistake was made in order to fully understand why the accident occurred and determine what would be needed to prevent a similar one in the future.  In this case, we can also assume that the accident was caused by inadequate oversight of the controller or lack of a double check of the mechanisms because an ideal system won’t allow one single mistake to result in a deadly accident.

Another fact worth considering is that the rail system in Poland is in the midst of a massive modernization effort.  Poland’s rail system is being modernized to prepare for the huge crowds expected to travel to the Euro 2012 soccer championship this July.  The modernization effort has been possible in part because of subsidies offered by the European Union, which Poland joined in 2004.  As part of the modernization, more connections have been added and more trains have been running on the track where the accident occurred.  It isn’t clear yet if any of the changes contributed to the accident, but any recent changes to a system are worth reviewing during an accident investigation.

As more information is found during the investigation, the causes can easily be incorporated into the Cause Map to capture as much detail as needed.  To view a high level Cause Map, click “download PDF” above.