[UPDATE by Sherwin: Here’s the full report (pdf) detailing the incident.]
Sound Transit’s preliminary report on last month’s Link derailment is complete. The train derailed while leaving the O&M facility, blocking one track and thus severely impairing the evening’s service.
According to the report, the operator ran a red light (involving a whole set of violated protocols), which was immediately detected at the operations center. He or she? She was instructed to physically check the switch and then move the train back off the mainline, but did not perform the physical check. That derailed the train.
Full press release after the jump.
FOR IMMEDIATE RELEASE — Dec. 22, 2009
Light rail derailment review shows operator error
Operator failed to follow rules for track access
A preliminary review of Link light rail’s low-speed, non-injury derailment on Nov. 16 shows the accident occurred after the train operator failed to follow established protocols for requesting access to the main line of the system and proceeded through a stop signal before entering the main line. The train then derailed while attempting to reverse course off the main line.
The two-car train was empty and coming into service when the operator moved through a stop signal on the access tracks at the Link Operations and Maintenance facility connecting to the Link mainline. Once on the mainline, staff at the Link Control Center detected the train in an incorrect position, ordered the operator to stop, then instructed the operator to visually check the track switches for correct alignment and then reverse course back onto the access tracks.
The review shows the operator failed to check the switches before walking to the other end of the train and reversing back down the access tracks. While making the reverse move back down the access tracks, the switch position caused two sets of wheels on the second train car to derail and block the southbound mainline tracks.
Under current protocols, train operators are required to stop at a signal, press a button to electronically call for a route, and radio the Link Control Center before entering the mainline tracks with their route information and to verbally verify the status of the signal before entering the mainline tracks. The route information sets the access switches to direct trains to the appropriate tracks. Once the route and switch settings are made, the control center and trackside signals approve moving onto the mainline when safe and give the operator permission to proceed.
The Link light rail system incorporates numerous safety features. The system is designed to automatically apply brakes to any train on a section of the tracks when it detects another train within an unsafe distance. No service trains were on the same section of mainline tracks when the accident occurred.
Sound Transit will continue to analyze the accident and review the Link signal and control system for training and operational improvements. Sound Transit will submit a final report to the Washington State Department of Transportation.
these things happen unfortunately. thankfully noone was hurt and the damage wasn’t worse than it could have been. i hope the driver doesn’t lose their job over this.
if you ever run a switch, just own up and leave it. don’t back up and think you can cover it up.
I think that losing his/her job would be justified. Not only did they disregard procedure, but then made it worse by not following the instructions to rectify the problem. Sounds like an easy termination to me. Of course, I’m not a Link operator, so I can’t, with certainty, know how bad of a violation this is.
You shouldn’t lose your job for simply running a signal … that can happen accidentaly … but failing to check the position of the switch before reversing and then causing damage … that would justify losing a job IMHO
They should lose their job. It’s a safety risk to everyone on and around the Link. These sort of accidents should never happen. Especially since this was caused due to gross negligence and laziness of the operator.
In the real world with real trains, if an engineer ran a red signal and then proceeded to disobey a dispatchers order, the engineer would lose his job. This is a pretty bad violation of operation procedures.
Safety is no accident.
It’s hard to believe someone would compound their error in running a stop signal by failing to follow the instructions given in response. In a way, I think it is good that this happened. It provides a real example of why these protocols are important without anyone having to get hurt.
you know how panicked they must have been? its easy to be the monday morning armchair quarterback but in the heat of the moment they must have froze like a deer in headlights when they hit that red signal.
People who freeze like a deer in headlights and cannot think calmly in a stressful situation should not be operating trains. The operators need to be people who will not panic.
you sound like management. also sound you have never made a mistake. must be nice to be perfect and able to cast stones.
Oh, I’ve made mistakes. I don’t think running a red should necessarily be an automatic termination. But this operator made a mistake, the mistake was pointed out to them along with instructions on how to rectify the mistake, which they did not follow. That’s a big whopper of a second mistake immediately following the first one.
you have to take into account that these guys and girls are used to working buses and light rail is a whole new ballgame to all of the operators.
Tim, that’s not the point. Are you missing the part where control specifically told the operator to check the switches before reversing? And the fact that the operator declined to do so? There’s a reason why those instructions were given, and the final result attested to that.
You can debate willy nilly about the ethics of the situation, but fact of the matter is that the operator committed only one mistake. The other was negligent disobedience.
i am holding out until both sides are heard. this is the first major accident on the brand new billion dollar light rail system and this incident got lots of bad press. you bet your ass ST is gonna crucify someone over this and make an example. i’ll hold my judgment until both sides are heard and concrete facts are known.
We’ve been sent the report. Sorry for the delay, but you can check the update for details.
unless i am reading incorrectly it says “Sound Transit’s preliminary report on last month’s Link derailment is complete.”
preliminary means just that.
I meant the PDF file I just attached to the top of the post.
But when a preliminary report concludes gross negligence on behalf of the operator, it’s pretty damning. It’s hard to argue around the fact that operator did not check a switch when required to do so by the dispatcher. That is a huge safety violation considering the dispatching center was showing an improperly lined switch. That is taking-out-back-and-beating sort of material.
“you have to take into account that these guys and girls are used to working buses and light rail is a whole new ballgame to all of the operators.”
And that’s the thing here. Rail is a whole different kind of operation from buses, one where following the rules and procedures is absolutely vital. Vital in the sense that if you don’t do it, there’s a significant chance that people will die. This requires a very different mentality from that of the bus driver, and if the train operator can’t follow the rules, then they should not be driving trains. The SPAD was an accident, and merits at least a stern talking-to, but not checking the switch was a much bigger mistake. It might show a need for some minor changes to dispatcher procedures, and the only technical measure that I think might be worthwhile is a derail or similar on the entrance to mainline track.
Tim F: Would you have those two Delta pilots who overflew MSP by about 200km re-instated because they weren’t perfect pilots? C’mon! Step back from your union’s predisposition always to blame management for just a moment. Think about passenger safety first and foremost, and then think about what this operator’s actions tell the owners of ST (you and me) about her/his suitability to be an operator.
It looks like the red light that was run was probably before the switch to the left. If the train was entering service, wouldn’t it have taken a route towards Beacon Hill instead of towards Sodo on the wrong track? There is a track from the O&M facility that crosses under the in-service tracks and the enters the track headed toward downtown. It seems that the train would have used that route if it was entering service towards downtown.
If that’s correct, the operator passed a red light, went the wrong way across the switch and realized the error after passing the next switch – at which point the train was located where it could have caused a crash with an operating train, depending on where it was in the block. That switch was positioned for revenue operation, toward Beacon Hill, so when the operator reversed the train, the final set of wheels went toward Beacon Hill while the rest of the train was on the tangent towards the O&M, hence the derailment.
This had the potential to be worse. There cannot be tolerance for operators who miss red lights and otherwise do not follow procedures.
Frank has a good point that is not clear from the accident report.
Was the blamed train operator on the correct track path to SODO IF the switches had been set correctly?
The apparent path she was on when the derailment occurred requires going north on the southbound track a short distance before getting to the criss-cross switch that would have moved her train over to the north bound track to SODO, her trains reported first destination.
Is this path through two mainline switches how trains routinely enter rush hour service from the yard at 3 pm on a weekday?
So why not use that other track noted by Frank that directly merges into the northbound track? See the overhead shot in Google maps.
Frank,
According to the Times article:
“The operator continued through an amber stop signal. . ”
In other words – the signal to “stop” is not RED but AMBER (yellow)? Can anyone familiar with Link operatio clarify this?
We are trained all of our driving lives to understand that amber/yellow means “caution” or “clear the intersection”. As a bus driver – I deal with yellow lights all the time, particularly at intersections with lights timed for 15 foot passenger vehicles rather than 40- or 60- foot ones.
If the signalling system has amber meaning “stop” – could it be an issue with overcoming conditioning to traditional signalling protocols?
I’m inclined to give the operator here a break – in spite of the seriousness in dollars and TV coverage. Certainly this kind of accident shouldn’t happen, but it doesn’t surprise me that the County is coming out with a press release laying the entire blame at the driver’s feet when there may be mitigating factors that they themselves might take responsibility for.
From what I understand – light rail is turning out to be frustrating for those operators who have taken it on, with reports of operators being disciplined at a rate as high as 30% for even the most minor of procedural oversights.
Stop is an amber horizontal bar. Proceed is a white vertical bar. Proceed on diverging route is a white 45 degree bar. Light rail signals are different than traffic signals in that they have a shape and a color.
and they are done this way to prevent confusion with drivers … unlike a grade separated system (subway) where they can have red/green block position signals
That is true! You don’t want to change signal styles throughout the system as that can cause additional confusion and pose another safety risk to both train operators and drivers.
After a summer in Europe with no car riding streetcars, I was used to looking at transit signals to see when I would be going forward. Then I was driving in Portland and almost ran a red because I had become so conditioned to the vertical/horizontal bars!
On the MLK portion, the signal will flash for 6 seconds before changing to a different aspect. The operator then can begin to accelerate or brake in anticipation.
For nearly a century, some railroads have use position signals. All lights are amber, but the position (vertical for go, 45 degrees for approach or warning, and horizontal for stop) determines the aspect of the signal. Interestingly enough, this was done for visibility reasons as amber light is very bright in foggy conditions.
http://en.wikipedia.org/wiki/Railway_signal#Position_light_signals
We may have been trained our lives to treat red as stop, etc. but this is a time where things change. Other light rail systems in the US use this same signal system with no confusion (such as the SLUT, TLink, Portland Streetcar, Sacramento Light Rail, Portland MAX, etc). I really don’t see how Sound Transit could take any blame for this. The operator violated the signal and did not complete a safety check as instructed by dispatch.
If a train went though an amber/horizontal signal on MLK, people could be killed. A penalty application of the trains brakes wouldn’t help either as the train has to PASS the signal in order for the brakes to be applied by the signal system.
Mike, you’re a Pennsy man, I see. Or maybe N&W (which was an all-but-subsidiary of the Pennsylvania).
At least our operators don’t have to deal with this;
wow. is there a signaling system? if so how do they know exactly where to stop and not foul the other track?
There is a line on the pavement, just as there is in our Link stations, indicating where the driver should stop the tram.
Imagine how wonderful Pine or Pike Streets could be from 15th Avenue down to the Market with only streetcars, peds and bikes. Yes, the #10 could be a streetcar if we had the political will.
i thought i saw a line in between the rails. where is the signal telling them to stop? do they just stop if they see an approaching train in the distance and wait for them to pass them?
As far as I can tell there are no signals. It looks like they just wait for the gauntlet track to be clear before proceeding. I’ll check it out next time I’m over there. I know a lot of the streetcar systems in Europe only use signals at the more complex intersections and use visual running rules elsewhere.
Or on a new Ballard-Downtown-West Seattle line: Ballard Avenue!
There probably is in cab signaling.
Pine would probably be a better street to make pedestrian/transit road as you would be exit from Wast Lake Station onto Pine. Also at a bare minimum they could make Pine from Pike place market to 5th/6th ave a Pedestrian/transit only road relatively easily (as some of those streets are pretty much over run be Pedestrians.) I think east of 5th/6th it would take some heavy politically will power.
Holy Krap! I’m exhausted just watching it.
I can’t even imagine the bell ringing that Link operators would do in a situation like that. They’d probably curl into a ball with their hand mashed on the horn.
Or this
Good candidate for High Speed Rail.
Bloggers and Posters. It’s been a fun year.
Happy Holidays to everyone, and be safe.
Mike
Zed,
Try driving a route that goes through the UW campus sometime. :)
FYI, the Times has updated its story that includes additional recommendations:
http://seattletimes.nwsource.com/html/localnews/2010572020_derail23m.html
Additional recommendations from the released report include:
• Add a red “Stop” sign and a sign telling operators to call the control center before entering the mainline.
• Use a simulator for controllers to practice emergency situations.
• Rework the automatic train-protection (ATP) system, so that it will stop a train that wrongly enters the main tracks.
Sound Transit has tightened its rules, so a train operator must call the base to confirm he or she has a white signal to proceed.
In the article it says that the driver was 6 minutes behind schedule. Does anyone know why?
That is all covered in Sound Transit’s operations manual. There is no need for a stop sign as there is already a signal. It seems a little over-the-top to call in for a proceed signal. That should ALWAYS be working. If it’s not, then the system is not safe for passengers to be riding on.
Though, it’s a good question why the ATP didn’t provide a penalty brake application when the the train passed a stop indication. Perhaps it did not warrant a penalty application though the way ST’s ATP is written (train within yard limits or below speed X).
The report said that trains are in street-running mode when leaving the yard and that the way the system is configured now ATP won’t stop the train when it violates the signal that controls entry onto the mainline from the yard.
I’m curious why the train would be entering service through the leaving service track. There is a grade separated underpass to the northbound track for entering trains from the other side of the maintenance facility, and a loop track all around it.
The DS has to be considered at least partially at fault for sending the car on this backward routing.
There seems to be changes to the other access track due to the yard expansion work going on. The loop track was severed. I don’t know if that had anything to do with it.
Oran,
Well, sure it would. If the loop is not intact a train exiting to the north can’t get to the flying junction. So the DS is not at fault; she or he had no choice but to order the opposing move.
Thanks for the info.