Rail safety and the human error excuse

Friday’s tragic Metrolink crash in Chatsworth, which killed 25 people, was not the only fatal rail accident last week. Less than an hour after the Chatsworth crash, a car was struck by a Metrolink train in Corona and the driver killed in a grade-crossing accident.

According to the Federal Railroad Administration, 74 people have died in Metrolink crashes since 1999 in California. And in a total of 821 accidents, 90 people have died on the Metropolitan Transportation Authority’s L.A.-Long Beach Blue Line from its inception in July 1990 to July 2008.

The root cause of most of these accidents is attributed to human error. But is this carnage always caused by train engineer error, or drivers trying to beat the train, or inattentive pedestrians trespassing on tracks? Flatly attributing accidents to just the actions of front-line operators -- or drivers -- is an oversimplification of the problem. Are we to believe, for instance, that all crossing incidents were because of negligence when the death rate is so much higher here than almost any other place in the nation?

What James Reason, a psychology professor at Britain’s Manchester University and the author of the book, “Human Error,” points out about many technological systems failures could also characterize last week’s crash:

“Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.”

At USC, 25 years of research into the safety of technological systems bears this out. It has shown that on many occasions, the error and its consequences are the result of a multitude of factors, including poor workstation and workplace designs, complicated operational processes, unreasonable mental and/or physical workloads and inadequate staffing, faulty maintenance, ineffective training, nonresponsive managerial systems, dysfunctional organizational structures and haphazard response systems.

For example, rail-crossing accidents could be attributed to a combination of human and technological problems, including design or system-induced errors, the design of an intersection, confusing and limited warning signs, dim and insufficient warning lights and inadequate gates. The size of a crossing may not allow for sufficient time to clear the way before the arrival of a 79-mph train. These poorly designed systems then lead to driver error or train engineer error.

The MTA is employing the same mind-set, organizational culture and safety practices that were used in the design and operations of its other lines in the building of the Exposition light rail on Exposition Boulevard. Once completed, it will connect Culver City to downtown, intersecting major, busy streets such as Western and Crenshaw. It will pass Foshay Learning Center and Dorsey High School, which have 3,400 and 2,100 students, respectively. The grade crossings adjacent to these schools will expose students to serious risk.

Despite a genuine interest in protecting public safety and a dedicated safety staff, neither Metrolink nor the MTA has been successful at addressing rail safety. They should be required to find out exactly how effectively their warning signs, signals and pedestrian systems are understood and complied with by diverse groups of people under a variety of conditions. And such studies and findings should be independently verified.

We need an overall shift in how we deal with rail design, construction, operation and regulatory oversight. We need to improve the safety culture of this industry and address human and organizational factors.

Unfortunately, the current regulatory, oversight and operational structure for ensuring rail safety in California is not working. It is diffused among many entities, such as the Federal Railroad Administration, the Federal Highway Administration, the Federal Transit Administration, the California Public Utilities Commission, operating companies, transit agencies, rail construction authorities and municipalities/cities.

Gov. Arnold Schwarzenegger should establish and empower a commission to address the fundamental problem of rail safety. This commission should analyze all available previous accident investigations, evaluate the implementation of past recommendations of the National Transportation Safety Board, study all the existing crossings and redesign all crossings and warning signs and signals based on technical and state-of-the-art human factors.

Many improvements are simple. After a deadly 2003 Metrolink crash and derailment in Burbank, the NTSB made two inexpensive recommendations: Keep a left-turn arrow red instead of flashing; extend a raised median another 25 feet. If this last recommendation had been put into effect, a death three years later would have been avoided.

Other improvements will be expensive, such as adding “positive train control” on railroad tracks, which can override mistakes by human operators and has been on the NTSB’s most-wanted list for years.

Whatever the cost of these changes, it would be worth it, when you consider the high economic cost of settling lawsuits and making repairs, and the intangible enormity of so many people killed or maimed.