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Dissecting Human Error: The Ohio Train Disaster
We’re going to look at the Human Error in the recent terrible Ohio Train Disaster. We know that this is still unfolding, and the authorities have yet to pinpoint the exact cause. But, we have a lot of information already, and we can make a few guesses about how the investigation is going to go.
We also know exactly what questions the lawyers are going to ask, because the lawsuits have just begun to fly.
Who am I to be telling you this?
Well, I am a former railroad employee, both my dad and grandfather had over 40 years of experience in railroading. Plus, I have a lot of work experience in and around bulk loading and unloading platforms in the chemical business.
I’ve audited a dozen or so refineries and/or producers of lethal chemicals as an ISO auditor.
So, I know the thought process.
I’ve also spent a week in the locomotive factory, and audited some railroad-related distribution facilities. Plus I know a lot about human failure.
Recap of What Happened: The Ohio Train Disaster
A train was traveling between Madison, Illinois and Conway PA. This train was traveling a main line, and was 1.76 miles long, according to Wikipedia. It had somewhere around 150 cars. Twenty of these were carrying various hazardous materials. This included some benzene, which is on the nasty end of the scale regarding chemicals.
When it reached the town of Salem, Ohio, it passed over a “defect detector” which indicated that one of the cars had caught on fire. A security video along the tracks indicated a condition the railroaders call a “hot box”, that is, overheated wheel bearing. The suspect car was carrying a load of plastic pallets.
It took about 20 minutes for the train operators, who were in a locomotive at the front of the train, to get the alarm, and put on the brakes. The wreck happened in East Palestine, OH.
When they “put on the brakes” they didn’t fool around, according to the sources below. They applied braking, and also emergency braking to slow the whole thing down. It’s hard to slow a 2-mile long train down. There is no talk of how fast it was going at the time but unless otherwise found out, it is usually between 40 and 50 MPH.
What that caused was a massive jackknifing situation. Railroad personnel and emergency crews arrived, and over 70 first responders from the area worked the blaze. The huge fire burned for two days. There were initial assurances that all was well and people should stay in their homes, and conflicting evacuation orders a few days later.
Lasting Effects
It’s three weeks later, and the area still smells like a stinking mass of vinyl chloride. The local EPA and state officials are trying to dispose of millions of gallons of contaminated dirt and water that was used in the fire. Locals are concerned that there are still toxic fumes in the area, which there obviously are.
The railroad, in its way, managed to get things back running on February 9th, but obviously the residents weren’t happy about it.
Effects on People
The residents of East Palestine OH are still annoyed. A lot of them have complained about health effects. This was sort of a vulnerable population anyway, like small town Ohio people are.
The lawsuits are just now starting to fly. Erin Brockovich is on the scene. The local politicians, who were previously all for deregulation and pro business, have suddenly turned environmentalists.
The effects of this will last for years. Every case of cancer in town will be blamed on this disaster.
Let’s Start with the Locomotive Engineer
The engineer of these things is just like an airline pilot, right? They have to have years of experience, a federal license, and extensive simulator testing, right?
Well, it looks like there is some standardization, and they won’t just hire these people off the street. The typical career path is to start as a $25 per hour conductor, which they do hire off the street.
As part of the initial training there is a Federal Railroad Administration test that the employees need to complete that tells them the basics. According to the FAQ’s I posted below, the job of “Locomotive Engineer” is determined by seniority. Norfolk Southern is about 3/4 unionized.
According to the FAQ below, once the “conductor” has enough seniority, they can bid on the “Extra Board” which means that they can get a short gig as a locomotive engineer for a shift or two, which could include nights and holidays. Once they build up time, as they say, they can bid on more steady work.
The identity and work experience of the poor guys who were running this train at the time have not been released yet
There were three people in the train at the time, the locomotive engineer, a conductor, and a “trainee.” There is a shortage of this type of worker. The hours are terrible, you have to work in the cold and dark. You’re expected to be able to read and write, but there are no special qualifications.
Engineer Training
There’s at least such a thing as a training simulator, right? Well there is. Here is a video.
Railroad Locomotives
If there is a good thing about any of this it’s that most of the railroad locomotives are still made by one company, and are standardized.
Each of the railroads may have nuanced operating procedures and requirements but at least there is some standardization.
The Job of the Locomotive Engineer
So here is the situation. The accident occurred at about 9 PM. It’s 600 miles between Madison IL to Salem, Ohio, which is more than the 12 hour limit for a train crew. So, this crew must have started their shift along the way.
So from their point of view, it’s cold, 9 PM, and dark. You got on at someplace like Indianapolis, and you’ve been on this thing for 10 hours.
Does the training and train simulator cover a situation where it is cold, 9 PM, and you have been on the train for 10 or more hours? Unlikely. It’s 39 miles between Salem Ohio and the final destination, Conway PA. So, let’s go out on a limb and say that they were at the end of their shift and possibly distracted.
The simulator is in a cushy office somewhere.
Impaired Workers
Ah, we have a video on this. Sleep deprivation is a form of workplace impairment that is at least as serious as any others.
Locomotive Engineer Investigation: To Do List
So if we were investigating this, for some legal reason, we could get together a to-do list, like this:
| Topic | Question | Records/Evidence |
| Training | Was the operator trained? | Look for training records, how long ago since training? What are the requirements for recertification? |
| Physical Condition | Was the operator impaired? | How long had the operator been on the train? How long since his previous shift? How many hours had he worked in the last day? What about the last month? Was he, or was he not, “impaired” or did he have “diminished function.” |
| Experience | How much experience? | How many similar situations? The records of previous trips can and will be examined to see if this fellow is “accident prone.” |
| Human Factor Management | Was the operator ticked off? | What was the psychological condition of the operator at the time of the decision to flip on the brakes? We would look for records of disciplinary action, performance reviews, and interviews with bosses and fellow workers. |
| Procedural Awareness | Did the operator know and follow the correct braking procedure? | The controls of these things are captured and it can be identified whether the operator followed the proper braking procedure. Look for the last training, and also look for past operator performance and determine if he is a “top gun pilot.” |
| Hazmat Awareness | Are there different procedures if a train is carrying hazmat? | What is the operator’s training regarding Hazmat? Was he aware that there were 20 cars of flammable material? If so, are there different operating procedures? Look for training records on Hazmat. |
| Signal Awareness | At what point did the operator notice the defect signal? | Were there sensory or other issues that might have caused some delay? |
| Quick Thinking Ability | What was the Operator’s ability to react to a disaster without panic? | Are these operators screened for psychological factors? Are they top gun pilots? Look for whether or not these employees are screened somehow. |
The Union
I should say something about this. We don’t know for sure if this is a union job or not, but if so, it is likely they are involved.
The role of the Union in this job is “nuanced.” On one hand, the union protects against overworking the crew. They also protect workers from unsafe conditions. At the same time, they allow a system where a promotion to a really dangerous job is done by seniority, rather than some measurement of reaction time or ability.
A lawyer will argue either point persuasively.
The high level trend on this industry is to try to reduce costs. Therefore, whereas a train had a crew of 5 people in 1960, they only have 2 now. Part of this is reliance on electronics and other equipment that provide additional safety. We’ll talk about that next.
Human Factor Management
We’ve talked about this at length. Part of the investigation is going to be to understand what kind of condition the operator was in at the time of the accident. Our investigation of human error in the Ohio Train Disaster will start with the engineer.
There are a number of external factors to consider as well.
You have a union employee that was nearly out on strike in November. He may well be at the end of a 12-hour shift. At the time of the wreck, he may have been inexperienced, ticked off, distracted, or otherwise impaired.
He, probably a he, probably got his job by seniority, rather than some special ability to operate a dangerous, 2-mile long motor vehicle with 20 cars of hazardous material in it.
Unlike in the relatively safe airline business, where the most heavily trained person in the system is the pilot, this fellow is a high school educated $25 an hour worker that recently came from the street.
The Lawyer’s Job
Ah, this. Well, in a civil case, a lawyer doesn’t have to prove “reasonable doubt.” All he or she has to do is prove the “preponderance of the evidence.”
It will be an easy job to plant in the brain of a jury any of these ideas. It will be all the more easy if the railroad did an imperfect job of filing these training and work records. “Training records? What training records?”
In this case, it will be up to the railroad to prove that they did everything right.
The ISO9001 Connection
So if you, the railroad, had a set of rules in place to select and train employees, and retain documented information, you would be better off right now, right?
And if your record keeping system was audited regularly, so that at this point you wouldn’t have to scramble around looking for records, you’d be much better off, right?
Right. This is why people get ISO certified. It helps them prove that they did their job properly.
There is more to be said on this topic.
PS: Have you seen my book on How Not to Fail at ISO9001? Here’s a link.
https://www.amazon.com/How-Not-Fail-ISO9001-Management-ebook/
Links and References
https://www.cnn.com/2023/02/24/us/ohio-train-derailment-east-palestine-friday/index.html
1960 train crew size
https://www.regulations.gov/document/FRA-2021-0032-0001
Norfolk Southern Road Foreman
Norfolk Southern Conductor
http://www.nscorp.com/content/nscorp/en/news/norfolk-southern-offering-starting-bonuses-of-up-to–5-000-for-c.html#:~:text=Conductor%20trainees%20should%20expect%20to,or%20near%20their%20hiring%20location.
Conductor
https://jobs.nscorp.com/go/Conductor/2685600/
Union Status
Maximum Shift for Train Operator
https://www.quora.com/How-many-hours-can-a-train-engineer-work
