Analysing accidents : When a train engineer sends 57 texts on duty

On September the 12th 2008 a Metrolink commuter train did not stop at a red light and crashed into a freight train in Chatsworth California.  Twentyfive people including the train engineer  (who was driving the commuter train) were killed and it was deemed the worst train accident of the decade in the USA.  It is a very interesting case because it received huge media attention and the finding that the train engineer had been text messaging a few seconds before the crash,  pushed the authorities in California to immediately put a ban on cellphones for train crews and then introduce a legislation regarding texting while driving cars.

Mr. Sanchez the train engineer had been texting all day on duty and had a record for using his cellphone at work, he also had been inviting young train enthusiasts in the train cab (the train “cockpit” ) and had even let some of them operate the train. He was certainly contravening a number of safety regulations on a regular basis and breaching standard security procedures.  However his behaviour was also set in a highly risky context of single track railway lines and lack of alarm systems on trains. It is worth spending a few paragraphs on the analysis of this accident because of the extreme nature of the engineer’s communication behaviours and the regulatory consequences it brought about.

This accident also highlights the contrast between the reliance of the railway system on operators’ attention and the lack of means put in place to support them. As in many other transport industries and safety critical environments there seems to be an increasing attention effort demanded of operators to ensure safety accompanied by a decrease in the measures that can help operators maintain that attention.  In particular the systematic reduction of personnel that has lead for instance trains to be driven by only one person alone in the cabin or the automation of many tasks leading to a purely supervisory role for the human, can lead to very isolated and dull work conditions. The use of the cellphone in those conditions suddenly takes a new meaning.

The Chatsworth train collision (wikepedia)

On the 12th of September 2008, the Metrolink and Union Pacific trains were travelling in opposite directions and crashed face on. Both trains were on the same section of single track that runs between the Chatsworth station and Simi Valley, through the Santa Susana Pass where three tunnels under the pass are only wide enough to support a single track. The line’s railway signaling system is designed to ensure that trains wait on the double track section while a train is proceeding in the other direction on the single track. The Metrolink train would normally wait in the Chatsworth station for the daily Union Pacific freight train to pass before proceeding unless the freight train was already waiting for it at Chatsworth. Tests of the railway signal system after the accident showed it was working properly, and should have shown proper signal indications to the Metrolink train, with two yellow signals as the train approached the Chatsworth station, and a red signal at the switch north of the station. That day however Mr. Sanchez the train engineer apparently did not see the red light and continued on his track.

A few days after the accident two teenagers claimed that they had received some text messages from the train engineer just minutes before the crash, and it emerged that the engineer was using his cellphone on duty. A further investigation showed that Mr. Sanchez had sent a text message 22 seconds before the crash and presumably been engaged in texting and had not seen the signal. When the National Transport Safety Board in charge of the investigation analysed the transcripts of the cell phone communication of Mr. Sanchez, it was found that he had sent and received 57 text messages that day. The content of the messages also revealed that he was planning to let a teenage train enthusiast come and operate the train. Mr. Sanchez it appeared had let other teenagers visit the cab.  It also emerged that Mr.  Sanchez had already been warned on two occasions, regarding his intense use of the cell phone in the cab.

The day after the NTSB confirmed the engineer was texting, and less than one week after the accident, the California Public Utilities Commission unanimously passed an emergency order to temporarily ban the use of cellular communication devices by train crew members, citing this accident and a previous accident where the train operator was using a cell phone. A week later, texting while driving an automobile was outlawed in California, effective January 1, 2009. There was no federal regulation prohibiting cell phone use by train crews at the time of the accident, but the NTSB had recommended the Federal Railroad Administration address the issue in 2003, after concluding cell phone use by a freight train engineer contributed to a fatal head-on train collision in Texas in 2002.  Following the Chatsworth accident,  the FRA administrator issued an Emergency Order restricting the use of “personal electronic or electrical devices” by railroad operating employees.


Analysing this case

This terrible accident is an extreme case in many ways because the behaviours of the engineer breached so many basic principles of safety and professionalism. However, as in all accidents there are multiple background causes and factors that create the conditions on which specific events or actions then trigger the disaster.  According to the NTSB, Southern California has more tracks shared by freight and commuter trains than anywhere else in the country, which is where the collision avoidance systems, called positive train control, are needed most. These systems automatically break and stop the train and are used in parts of the Northeast and between Chicago and Detroit, but railroad officials have said the technology costs too much money and is not reliable, and therefore had not been yet installed by Metrolink.

Another information of relevance was that the engineer Mr. Sanchez was on split shift meaning that he had an 11h work day composed of two shifts with a 4h break in the middle. That day he had worked from 6am to 10 am had a break until 14h and started his afternoon shift that would last until 21h.  This type of shift has been recognised as allowing little rest to the drivers and reducing their level of vigilance and awareness. Finally another surprising fact that emerged was that on the other train the Union Pacific Freight train, the train conductor had exchanged 42 text messages that day while on duty. This seems to suggest that texting while operating a train could have been a common activity and that Mr. Sanchez’s texting was not as extreme as it seemed.

The detail of the investigation allows us to lift a veil and look into the reality of the job of train crews and consider what the use of personal communication devices reveals of demands of this activity.  The fact that in the Chatsworth accident crew on both trains had been texting heavily all day suggests that this may be a common practice which in turn means that the job is somehow inducive to this type of behaviour. There are a number of hypotheses that can be made on why conductors or engineers are indulging in texting on duty : mental underload if the tasks are too repetitive and boring can push operators to look for outside stimuli, isolation can also push the operators to search for contact, excessive confidence can lure operators to think they can divide their attention successfully.  It is well possible that the train engineer Mr. Sanchez had been completely distracted by his communication activities and simply ignored all signals, it is also possible that he was relying on regular habits (the freight train always waits for the metrolink train to pass first so no use to check…) to lower his vigilance.

In our view simply banning cellphones from train operations does not resolve the issue of safety and attention. Cell phone usage on duty, should alert us to the fact that isolation, long shifts, repetitive tasks are not sustainable and that they have serious consequences on operators’ alertness, vigilance and safety.

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