Wednesday 12 September 2018

Chatsworth 10 years on

On this day in 2008, a Metrolink outward bound commuter train was in a head-on collision with a freight-train coming round a corner on a single track part of the Los Angeles County rail network outside Chatsworth, CA. The combined impact speed was about 80 mph = 140kph and 25 people died from blunt trauma. Many dozens of passengers were injured: ". . . head injuries, multiple facial fractures, chest trauma, collapsed lungs, rib fractures, pelvic fractures, leg and arm fractures, cuts in the skin and soft tissue. Some have blood in the brain". And so it was a bloody mess. Two people in particular didn't come out of it with reputation intact: one dead and one miles from the accident.

The first was Robert Sanchez, the engineer, who was at the end of an 11 hour shift in which he'd brought the train in from outer suburbia: between starting the inbound run at 0644hrs and arriving in LA at 0853, he exchanged 45 txt msgs. On the way out of town in the afternoon he received 7 and sent 5 more txt msgs including one 22 seconds before the freight train appeared in sight 4 secs before impact. 9 minutes earlier he had sailed through a red light onto the track that was accessible both for NW and SE bound trains. Many of the txts were totally trivial communications with a teenage trainspotter. It seems certain from subsequent investigations that Sanchez ran through the red while suffering from inattentional blindness. All his attention being directed at his phone. Timeline and context (including text of txts) from the NTSB. I've written about the lethal effect of txtn while drivn a car in the context of Werner Herzog's arresting film  From One Second To The Next. I feel the pain more than some having been whacked off my beautiful pink road-bike 20 years ago by a woman looking for her phone rather than at the road.

The other person who suffered reputational damage was Denise Tyrrell, the spokesperson for Metrolink. The day after the crash, she told the press that the evidence was pointing at one of Metrolink's engineers being at fault in that he went through a red light. She believed that it would help clarify things by being up-front rather than ob-fusc, and she secured approval from Metrolink's CEO before going public. Two days later she was forced to fall on her sword and resign because her comments were premature and inappropriate. Depending on who you are, you'll either agree with the management or be outraged that a comparatively low-level [female] employee was 'retired' rather than the buck stopping with David Solow the CEO. I know my father, who was a ship-captain, had strong feelings about the bloke in charge being in charge and so ultimately responsible for everything and everyone below him in the organisation. If an organisation allows drivers to goof off on the job and 25 people die, then the CEO need to own it. Your outrage, if any, at the shabby treatment meted out on Ms Tyrrell is probably coloured by the fact that she was right in her assessment. How would you feel, how would Sanchez's family feel, if her immediate-aftermath assessment of cause turned out to be incorrect? See: it's not so easy, is it?

By coincidence [or because we love each other very much] My Son the Engineer aka The Boy is currently researching a pitch to sell UK railway safety protocols to the USA. After a clatter of  turn-of-the-century railway fatalities in the UK exposed systemic failures in management, accountability and training, the stakeholders got together to prevent these 'normal accidents'.  Last December, in the wake of the rail-crash near Dupont WA, I wrote about how automation is working fine and making money for Amazon but is too costly to implement in the nearby railway. If things are too costly to implement, you need a Risk Assessment to ask if it's going to be more costly to not implement. It's a bit like the story of the magnate who was too busy to meditate for half-an-hour a day; his guru / personal-trainer's conclusion was that he should therefore meditate for a whole hour a day.

Premature and inappropriate is in the air today in Ireland because the Scally Report into the Cervical Check Scandal [prev] was released to the Irish Times and RTE before being presented to the cabinet or shown to the women who were done for by the whole debacle. Much indignation that Dr Scally had exceeded his brief and made a list of recommendations that, in his opinion, would preclude much of the need for a full scale, all-lawyered-up tribunal of enquiry. When the report, with the easy headlines put in context, was read by the main cervical victim group, they agreed that it was measured and sensible and, importantly, immediate-of-effect (if the government chooses to implement the recommendations).

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