New York Metro-North Train Crash Offers an Opportunity
The deadly train derailment that occurred on Dec. 1, 2013, north of New York City apparently offers another example of an industry—or at least one heavily traveled commuter line—that is ripe to learn the lessons of safety science. With Dr. Lucian Leape’s discovery 25 years ago of the science of human error, healthcare began to assimilate knowledge from other disciplines and to improve safety by addressing the underlying, latent causes of error and harm. It appears that railroads would benefit from the same.
In “Train Had a Warning System, Just Not in the Operator’s Cab,” New York Times reporters Matt Flegenheimer, Ford Fessenden, and Henry Fountain, describe conditions and attitudes indicating that Metro-North and other responsible authorities lack a “culture of safety”:
The Metro-North Railroad train that derailed on Sunday included a system designed to warn an operator of a potential accident. But such an “alerter,” which can automatically apply the brakes if an operator is unresponsive, was not in the cab where William Rockefeller apparently fell into an early-morning daze at the controls. It was at the other end of the train.…
The derailment was the deadliest in New York City in more than two decades, prompting a federal investigation and leading local authorities and prosecutors to collect evidence for a possible criminal investigation into the actions of Mr. Rockefeller, who has been suspended without pay.
That a warning system existed, not just in general but actually on the train that crashed, and that the train operator may be treated as a scapegoat, complete with criminal prosecution, is chilling. How to ensure that safety lessons—often derived from dreadful accidents—are disseminated widely, not just learned at the affected hospital, is an ongoing challenge in patient safety. We should be concerned as well that the broader lessons of safety science apply across all industries and organizations, to prevent others from having to learn them at terrible cost.
An article published one week later offers some hope that at least some of the railroad authorities understand that multiple factors contributed to the crash and that investigation must extend far beyond the actions of the train operator. This apparently, surprisingly, is a new approach to safety in passenger railroads. Flegenheimer reports,
Federal transportation officials said on Thursday that they would begin an extraordinarily rare review of the operations and “safety culture” of the Metro-North Railroad — the first such investigation ever conducted for a passenger railroad.