On Sunday, April 3, 2016, an Amtrak train traveling southbound from New York City to Savannah, GA. struck a backhoe with Amtrak personnel performing maintenance near Philadelphia, PA. The incident killed two Amtrak workers and injured more than thirty passengers. This was a tragic event, but one that could have easily been avoided had the parties involved been aware of their blind spots when it came to their personal SafetyDNA.
Let’s take a closer look at the events leading up to this incident through the lens of the SafetyDNA S.A.F.E. Model and see if we can find where the breakdowns might have occurred. As a reminder, the S.A.F.E. Model refers to the following:
Stays in Control – Emotional control when under significant stress or deadlines
Aware of Surroundings – Attention to details, awareness of the most immediate hazards
Follows Rules – Attitude toward rule compliance
Exhibits Caution – Comfort level with risk, impulsivity, and thrill seeking
According to industry experts there are several safeguards in place to ensure an incident like the one that took place on April 3rd does not occur. So where was the breakdown? The N.T.S.B. has not yet completed their investigation as to the main cause of the incident. However, proper execution regarding Foul Time procedures should have prevented this from happening.
In layman’s terms, foul time is a method of establishing working limits on controlled track. When maintenance is being performed on a section of track, the dispatcher or control operator will initiate foul time. During foul time, workers are notified that no trains will operate in the area where the maintenance is being performed. Upon completing maintenance and notification sent to the dispatcher or control operator that all workers are clear, foul time may be lifted.
In this incident, a backhoe was positioned on Track 3 while maintenance was being performed on Track 2. Track 2 was removed from service and Track 1, 3 and 4 were granted intermittent foul time. However, during the maintenance activity, Amtrak Train 89 was routed onto Track 3 where the backhoe was struck.
The railway worker onsite that day claimed that the proper protections were in place at the time of the incident. But, those with firsthand knowledge of the incident claim the failure was due in part to a breakdown in communication during a shift change.
While an incident such as this one may involve multiple factors, there are usually one or two that standout. If we apply the SafetyDNA S.A.F.E. model, we can see where the breakdown may have occurred.
Stays in Control
A person’s SafetyDNA is most evident when pressure is at its highest. Regardless of the job being performed, train operator, maintenance worker, or shift foreman, all were faced with staying in control during a stressful situation. The level in which control is maintained has a great deal to do with the outcome. It’s possible to maintain control yet still be unable to prevent a tragic event due to other factors. Control very well could have contributed to the incident but other factors played a larger role.
Aware of Surroundings
Witnesses reported, “The Amtrak conductor blew the train’s horn, but construction workers were unable to clear the tracks in time.” In any dangerous situation, you need to have heightened awareness. Even if you believe all safety procedures have been followed, you should still be aware that something could fail. In this situation, the use of hearing protection may have affected the worker’s ability to hear the train’s horn. So, while awareness may have played a role it doesn’t appear to be the leading factor.
If foul time procedures are designed to prevent this type of event from happening, then how did it occur? The simple answer is the rules were not properly followed or applied. Whether it was in the implementation or communication something happened that caused a major violation of foul time to place a train traveling at more than 100 mph on a track where maintenance was being performed.
Performing maintenance in a situation such as this requires an extra degree of caution. Lives of both Amtrak personnel as well as passengers are at risk. Even though the parties involved believed proper procedures were followed, the extra step of ensuring communication was effectively handled could have helped prevent this incident. Exhibiting extra caution even to the point of over communication is never a bad idea when lives are at stake.
The N.T.S.B. has yet to complete its investigation and admittedly my knowledge of this tragic event is limited to media coverage. However, from the information available it appears the leading factors in this incident were Following Rules and Exhibiting Caution. Primarily, properly implementing the foul time procedure and communicating that construction was taking place in that area of track. Knowing one’s SafetyDNA can provide very useful insight into those personal blind spots that place us at risk and hopefully avoid incidents such as this in the future.