Railroad Accident Investigation A Presentation to Exporail

Jim Grady

Assistant Vice President - Technical Services

Association of American Railroads

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Topics to be Discussed

•Why Here – Why Now

• Investigative Process

•Analysis

•Final Report

PRIMARY MISSION OF A TRAIN ACCIDENT INVESTIGATION ANSWER THE QUESTIONS: WHY HERE? WHY NOW?

Why Here? Why Now • Upon arrival the investigative team will looking to answer

the questions of “Why Here? Why Now?

• Of all the trains that traversed this point why did the accident occurred at this location at this time.

• What made this time/location unique

• Train make-up

• Time of Day

• Weather

• Crew

• Rolling Stock

Investigation Process

• The process must;

• Be Unbiased

• Be Timely

• Include Multiple Disciplines

• Deliver a report of Corrective Actions learned from the findings

Investigation Process

• The leading agency in the investigation of train accidents in the US is the National Transportation Safety Board (NTSB).

• NTSB follows a protocol that breaks down the investigation into six (6) distinct disciplines

Chatsworth, CA

Investigation Process

• Determine the Point of Accident

• In case of a collision determine point of impact

• In case of a derailment determine the point of derailment

• Where the first wheel left the rail

• Break into Investigative Groups Focused on a Specific Discipline:

• Determine the sequence of events

• Collect all available information at the scene

• Identify safety deficiencies through the lack of adherence to standards and rules

• Develop a cause through consensus among the groups

• Develop and distribute recommended corrective actions.

Operations •OPERATIONS GROUP•History of the accident train, crewmembers',

and dispatcher duties.• Train • Train make-up and route• The handling of the train via the use of the

“black box” (event recorder) • Crewmembers •Hours of Service• Training • Experience and Qualifications • To operate in this territory

Operations (cont’d)

•OPERATIONS GROUP• Environmental • Time of day •Weather•Heat may have caused

a track problem • Flooding may have

caused a washout • Compliance with Standards

and Rules Y/N

Mechanical • Mechanical group will inspect the locomotives

and rolling stock

• Determine what was the first locomotive or rail car to derail

• Document the state of the locomotives and rail cars

• Review of maintenance records

• To Include

• Recent Inspections

• Recent Repairs

• Required Inspections

• Compliance with Standards and Rules Y/N

Survival Factors • SURVIVAL FACTORS Group

• Documentation of impact forces and injuries as a result of the accident

• Review how well an evacuation was performed if one occurred

• Emergency Response –Community emergency planning and all crash-fire-rescue efforts.

• Compliance with Standards and Rules Y/N

Human Factors • HUMAN PERFORMANCE

• Study of crew and dispatcher performance and all before-the-accident factors that might be involved in human error including fatigue, medication, alcohol, drugs, medical histories, training, workload, equipment design and work environment.

• Compliance with Standards and Rules Y/N

Signal• Signal Group will inspect the signal and

communication systems being used a the time of the accident.• Determine if the signal and

communication systems were working as designed

• Document the signal and communication systems

• Review maintenance records of the signal and communication systems

• Compliance with Standards and Rules Y/N

Track • TRACK GROUP

• Document the point of derailment

• Document Track Stations

• Look for anomalies present at the time of derailment

• State of the track

• Review of maintenance records

• Compliance with Standards and Rules Y/N

Analysis• Once each group finishes the collection of the facts the

next steps will be to see what possible causes for the occurrence of the accident have been found• This process is like the separation of the “wheat from the chaff”

• Note earlier in several of the disciplines there was the bullet

• Compliance with Standards and Rules Y/N

• Those Standards and Rules that rated a Y are considered the “chaff”

• Those Standards and Rules that rated a N are considered the “wheat”

• It is the “wheat” that will direct the investigation’s focus for cause

Analysis• The investigative team meets and discusses each

disciplines findings

• The discussion will focus on what Standards and/or Rules were note to be insufficient to prevent the accident

• A review if the Standards/Rules were sufficient

• Note what was lacking in the Standards/Rules

• Note what Standards/Rules were not complied with and why

• Note if no Standards/Rules were in place that could have prevented the accident

Analysis

• Once the Standards/Rules identified to be either not complied with, insufficient or non-existing the team will make these findings as issue areas. • These factors are found failures present at the time of

the accident• Many times railroad accidents have multiple causes

Final Report

• After the facts were collected and analyzed by the each group the team determines what deficiencies were present at the time of the accident.

• The team determines from the found deficiencies what was the causal factor(s) that triggered the event

• The investigative team will make recommendations that will prevent future accidents from occurring based on the causal factor(s) found in its investigation.

THANK YOU

QUESTIONS?

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