As a retired National Transportation Safety Board railroad and rapid transit accident investigator, the more I hear about the Dec. 18 derailment of Washington state Amtrak Cascades train 501, the stranger it gets. Confirmed “facts” seem to be very few so far.
The National Transportation Safety Board is investigating the accident, which killed three people and injured more than 50 others, and is still trying to determine the probable cause and prevent such accidents in the future.
People have an innate need to know, particularly with unexpected public transportation accidents as part of their own sense of security and trust. The sooner we know, the better.
But we could be waiting a while before we hear from the safety board about what led to the derailment. The length of time the safety board has taken to produce “the facts,” let alone a public report, has greatly lengthened over the past two decades, mostly due to safety board management.
An accident investigation has gone from nine months to over two years for a “major” investigation such as this accident. The prolonged process has been sold to Congress and to the public as a way to produce more thorough reports and recommendations, although the success of these efforts is debatable. In the interim, the public is left guessing.
At this point in the investigation, the “field phase,” safety board investigators work fairly quickly to garner the facts, which will be consolidated into a single report. After this stage the process slows down, especially with high-profile accident investigations involving public hearings and senior-level managers. Ultimately, a final report is far in the future.
With this incident, there appear to be a number of safety issues, including the choice and costs associated with the railroad route itself. The most important looks like a human performance safety issue.
It appears that there were two people in the lead locomotive control cab of the train who were both injured and hospitalized: an instructor engineer, and another engineer who was learning the territory and qualifying to operate the train along the route.
The derailment occurred on the first day of higher-speed service. The propriety of conducting such training on the inaugural run of the service is debatable. Railroad union hearsay alleges that the two locomotive engineers lost track of where they were because much — if not all — previous route qualification training had taken place at night when busy freight railroad traffic could accommodate the luxury of a non-revenue passenger train on multiple training runs. As a result, on the maiden run the two engineers had difficulty associating daytime landmarks with their ever-changing location.
To a large extent, this is the main tool engineers use to track their location. The environment’s physical characteristics are crucial to knowing one’s location, just like when we drive our cars. However, there are additional aids available depending on the train control systems in place.
In addition, there are allegations that these prior night training sessions had upwards of six people in the locomotive cab in order to qualify as many engineers as possible to operate trains along this route in the short amount of available time before service started.
This crowded training occurred despite the fact that there are usually only two seats in the rather small cab. Training for a route varies depending on the experience of the engineer and can require as little as two trips to as many as 10 or more.
Thus, it is alleged that none of the qualifying engineers were getting the undivided attention needed to memorize the route without distraction. In a nutshell, this is what is rumored.
If true, it places the onus on those managing this operation and their judgment and experience, or lack thereof. The lack of competent oversight by management and/or policy may lie at the root cause of this accident. But we, the public, won’t know for sure until the National Transportation Safety Board gets a sense of urgency and tells us.