I heard the headline from CBS News on my car radio:
“NTSB to cite operator error in deadly Amtrak derailment.”
The news story came on the eve of the National Transportation Safety Board’s (NTSB) public hearing regarding the May 2015 disaster outside of Philadelphia. The derailment killed eight passengers and injured 200 others. The subsequent news stories repeated "operator error." The phrase makes it sound like the engineer hit the wrong switch or pushed the wrong button. I wondered whether "operator error" in the headlines was a repulsive example of click baiting.
The NTSB’s statements and testimony about the Amtrak 188 disaster are filled with declarations that blame the train engineer for the disaster. “He,” “his,” and “the engineer” weave through the NTSB's declarations. The agency's conclusion on the incident's probable cause was the engineer’s “loss of situational awareness.” Board member Robert Sumwalt said:
"This is really not a complex error. It’s a very basic error.”
NTSB investigator Steve Jenner said:
“This is a standard human error."
No wonder "operator error" punctuates the news stories' headlines and lead sentences. NTSB member Sumwalt said this about the train engineer:
“He went, in a matter of seconds, from distraction to disaster."
Distraction? A nearby commuter train had been struck by rocks. The Amtrak 188 engineer was listening to dispatchers who were discussing the emergency situation. What the NTSB calls “distracted” I call “paying attention.” (And why is there no co-engineer on the train, like a co-pilot on a plane?)
Blaming the operator for being "distracted" overshadows the real story: The railroad industry's and regulator's failure to equip trains with positive train control (PTC). This braking-system technology is a safety back-up for the engineer's operation of the train. It is designed to prevent incidents such as over-speed derailments and train-to-train collisions. The chairman of the NTSB, Christopher Hart, calls PTC a "technological safety net." It was not in place on the train involved in the Amtrak 188 disaster.
NTSB member Bella Dinh-Zarr, PhD, MPH questioned her colleagues' focus on "operator error." Dinh-Zarr is a public health scientist who specializes in injury prevention and transportation safety. (She's also an active member of the American Public Health Association.) The Associated Press reports that Dr. Dinh-Zarr urged her NTSB colleagues
"...to put more blame on the lack of positive train control... 'Eight people have died, dozens more have been injured — life-changing injuries — because the government and industry have not acted for decades on a well-known safety hazard."
"I ask, why does our probable cause focus on a human's mistake and what he may have been distracted by?'"
The Atlantic's David A. Graham elaborates on Dr. Dinh-Zarr's remarks at the public hearing:
"As the board voted on conclusions...[she cited] the importance of PTC [and] proposed relegating engineer error from the probable cause of the accident to contributing cause, while naming the lack of PTC as the probable cause.
NTSB staff, however, opposed the switch, as did Chairman Hart, noting that the engineer is still responsible for following rules and that PTC is a safety net; Dinh-Zarr’s attempt was defeated. ...Dinh-Zarr pointed out [that the] NTSB has been advocating for PTC since 1970."
Kudos to NTSB member Dinh-Zarr for challenging her colleagues' proclivity for citing "operator error" the agency's reports. Let's put the responsibility where it belongs for the lives lost and harm caused: The railroad industry. Their foot-dragging, lobbying, and legal challenges against PTC makes them culpable.
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There are other ways to make the process of driving the train less prone to errors. You cannot say that the only solution.is PTC. A second person in the cab? Visual warnings, like speed limit signs outside of the train? How many other things could have lessened the possibility of this tragedy occurring? It's almost as though the system dared him to screw up instead of making it difficult to do so.
Whenever "operator error" is cited as the reason for an incident in a complex system, it generally means that all of the components of that system that should have been in place to prevent disaster have failed or were never in place to begin with. The unfortunate operator is best remembered as the first victim rather than the proximate cause.