DRAFT: This module has unpublished changes.

Hoboken Train Wreck: 2016

 

The Hoboken train wreck of 2016 was one of the worst train wrecks in American History, oddly enough it occurred when technology and train advancements were at the paramount of the technological era. Unfortunately, this wreck was a result of human error, therefore, technology most likely wouldn't have played a major part. But, on the contrary, if there was an emergency brake that worked when the train was traveling too quickly toward the platform then this accident could've been completely avoided.

 

 

The Hoboken train wreck of 2016 resulted in over 100 injuries as well as 1 death. The death occurred when the train crashed into the platform at high speeds causing the roof of the platform to collapse, and debris to fall. The day started when commuter train 1614 carrying roughly 250 people headed for Hoboken, NJ from upstate New York at roughly 8:30 am. The train approached the platform at an alarming 21mph and the collided with the bump at the end of the track and continued right over it resulting in all the damage that occurred (www.ntsb.gov). The wreck occurred when the train's engineer failed to pull the brake and slow the train down at the appropriate time. In fact, the engineer somehow made the train increase in speed as it approached the platform. After the investigation, it was concluded that the train's engineer suffered from a disorder called sleep apnea (theguardian.com). Sleep apnea is when the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow (www.nhlbi.nih.gov). This occurrence results in lack of a sound nights sleep as well as a constant disruption of the brain during sleep. This prevents the mind from recovering like it should during the sleeping process, the engineer was definitely not as alert and sharp as he should've been when operating the train; this is a direct result of the sleep apnea disorder. With that being said and known, this opens up many other doors as to whose to blame for this accident.

 

At the top of the list of errors would be human error but as to who was at fault, that's a whole another question. The commuter train, the engineer, and all the other workers are all overseen or owned by the New Jersey Transit, they are responsible for the people that they hire and for the equipment that they issue.  The specific engineer of the Hoboken train wreck was operating a commuter train at the height of rush hour for years and yet no supervisors, executives or physicians thought to test if he had any health issues. Being an engineer for the train is a very important job and requires alertness and the correct action at all times. Therefore, the human error could be directed toward the engineer himself, Thomas Gallagher or some say the engineering fault occurred on the side of the New Jersey Transit. The New Jersey transit is supposed to follow a safety protocol advised by the Federal Railroad Administration (FRA) however they failed to do that. The New Jersey Transit is supposed to screen all of their employees, especially the train's engineers for disorders such as the one that Gallagher had. However, there was no paperwork nor evidence that the screening ever took place for this individual. Therefore, the New Jersey Transit is definitely at fault for this engineering disaster being that they failed to follow a safety protocol that would've greatly reduced this accident from occurring. When putting these two human errors together, it greatly increases the probability that an accident such as this would occur. Sleeping disorders such as this one is a major reason as to why many highway and railroad accidents occur all over the world, and it seems that companies are taking more initiative to control the issue.

 

Just like every other engineering disaster, engineers learn from the disaster that occurred and makes changes to the safety protocol and the building materials used. Unfortunately, the majority of these disasters result in severe injuries and even deaths. Yes, it's good that change comes from these disasters however it would be a lot better if these disasters never occurred and lives were never lost or affected. Another issue that is overlooked with the Hoboken train wreck was the fact that there was no extra equipment to "save" an engineer when the human error does occur. What I mean by this is that there was no sensor or machine operated brake that would slow the train down if it was approaching the platform at high speeds. If the technology like this was existent during this accident then there would not have been the Hoboken Train Wreck of 2016.

 

The relationship between risk and complexity seem to go hand in hand. Train systems, are complex. They are open, meaning that they’re influenced by the environment while simultaneously influencing the environment. When we have open systems; especially at a large scale like the NJ Transit; it becomes difficult to set boundaries and calculate risks. Sidney Dekker’s book Drift into Failure emphasizes that open systems have a path-dependence. Which means that their past is co-responsible for their present behavior; so taking history into consideration is vital when attempting to predict future failures. With all of these interactions; whether its politics, ridership, economy, weather, maintenance, governance it is easy to predict that there can and most probably will be a mishap, the problem would be specifying which interaction caused the failure.

 

 

 

 

Going back to Dekkers theory of path-dependency we can see that even before the Hoboken wreck, the transit was already under investigation for violating safety rules and operating protocols (Bloomberg, 2017). Unfortunately, the railroad administration was not quick enough to have the transit comply with the safety demands of the people and the environment. Another risk the NJ Transit faced being an open system was politics; specifically budget cuts. They were unable to keep up with the rising demands of the nations third busiest commuter rail. Because of the budget cuts, many trains stopped operating; which mean even more people (approx.. 1 million people on an average weekday) on the same carts; causing more wear and tear. All these small mishaps led to something Dekker defined as decrementalism, which means adaptation around goal conflicts and uncertainty produces small step-wise normalizations of what was previously judged as deviant or seen as violating some safety constraint. (Dekker, pg. 40). This is where psychological factors such as normalization of deviance come into place. Here we have merely four out of the dozens of possible risks that contributed to the Hoboken train wreck.

 

 

 Now if you recall the risk equation, it entailed more than the vulnerabilities that we’ve talked about; because it wouldn’t be much of an equation with just one expression now would it?. But the vulnerability (times) the probability of failure (times) the cost (lives/money/industry damage/environmental damage, etc) divided by mitigation, which shorthand are means to reduce any of the risks factors.

 

 

 Moving on to the rate of occurrences, just one year before the Hoboken train wreck the NJ Transit was first on the list for total mechanical failures, breakdowns, and fines according to the NTD (FTA, 2015). Not only that but the NJ Transit in the five years prior to the crash saw more accidents than any other commuter railroad in the entire country.  157 accidents from 2011-2016 (T&L, 2016). So it is safe to say, the rate of occurrences is awfully high.

 

 What did this crash cost us?  so far it has been over 6 million dollars, in repairs and lawsuits. But more than that, a life; that cannot ever be replaced or compensated for.

 

Mitigation in the case of the Hoboken train wreck is PTC positive train control, which is a system of GPS, radios, and computers that monitor trains and can stop them from collisions, speeding and derailing (the train was going more than double the speed limit when it derailed at the Hoboken station). The problem with this is that it makes an already complex system, even more complex. As we know relying on automated and autonomous control systems has had its downsides, like the inability to regain control in case the system was to go out of control and make diagnosing a problem a heck of a lot more difficult. If PTC had been in place, it would have slowed the train down and the accident would have a less possibility of happening. There we go again: technology: 1, humans :0. Of course, this requires millions of dollars; that the transit did not have.  The federal government mandated that the PTC control should be installed on all commuter trains in the US by the end of this year. This is costing the NJ Transit over $300M dollars (NYT, 2017). This also includes modern bumper posts equipped with hydraulic shock and absorbers at the stations that do not have them, which is all the tracks but one on the NJ Transit.

 

All of these things combined have given us an overlook at the consequences of failure; and all the risks which were reflected on the tragic afternoon of September 29, 2016.

 

The impact of this disaster was definitely significant. It cost the New Jersey transit company 6 million dollars on the train alone. This means that between the cost of the injured people, and the damage the train station, the amount of money used to fix was tremendous. This incident also caused other services that the New Jersey Transit had operating to be shut down. They had to be suspended for most of the day because officials feared that the roof of the building would collapse. Luckily, they were able to resume some of the train lines by the end of the day. However, to help reduce the amount of money lost from people trying to take the trains, the Metro-North Railroad allowed people who had tickets for the Hoboken station use them at theirs. This honoring of the tickets cost the New Jersey Transit a total of $664,000. While there are still on-going lawsuits due to physical injuries, so far one woman has received $475,000 for her injuries and $91,000 to settle injury claims from several crash victims.

 

After this happened there are many changes that the National Transportation Safety Board recommended and ones that the New Jersey transit implemented immediately. One thing that they did was implement a civil speed enforcement technology to keep track of the speed of the train to make sure that the brakes were working properly. The made it so that if the train was going faster than a set speed, it would mean that the brakes are not working at the ability that they should be. If that is the case, the brakes would have a full-service check to ensure that they are working properly. One change that seems like it is important to mitigate the chance of an accident like this and others to happen again was to make it so that upon entering the train station, the conductor of the train has to move to the front of the train. They did this because it allows there to be a second person to watch the speed of the train, and the distance that the train is to the station. The Hoboken station also required trains to reduce the speed that they come into the station. It would now be 5 mph which is half of the original speed. The last thing they also changed was to the bumpers. They changed the design of the bumpers so that they are able to better stop the train and prevent less damage to the train itself. After determining that the cause of the accident was due to undiagnosed Obstructive Sleep Apnea, they implemented a program that ensures that the forms for Sleep Apnea are completed and reviewed. They also made it so that in the event that an employee meets the criteria for Obstructive Sleep Apnea, they will be removed from service until they have been treated.

 

The social impact of the crash led to a few negative impacts on the train station. From a conversation that the NTSB had with Bob Lozanski, a New Jersey Transit Foreman, they had to put Thomas Gallagher, the engineer that caused the accident, on a 30-day suspension. They also took away his certification and he had to attend recertification class. Along with not having a running terminal for the track that the train in the accident was on, the Hoboken train station had many delays and crowded trains for many weeks. The Hoboken terminal itself was closed for 10 days and the repairs for the station would not be completed until 2019. The New Jersey Transit is one of the most dangerous train stations because they neglect safety. They were cited many violations by federal officials and their trains broke down more than most. A few commuters have said that they think the safety of the New Jersey Transit has gotten worse over the years. For example, Carlos Garcia, a Pascack Valley Line commuter says that “NJ Transit has been just as bad, or worse, in the past year. When it comes to safety practices, I haven’t noticed any obvious changes.” And we also had Sheldon Kest, a person that was riding the train said “I’ve been riding trains for 50 years… I don’t know when I’ll ever be able to board a train again”. These are examples of the deterioration of the trust of the commuters to the New Jersey transit even after the accident happened and there was time for them tOverall there were not that many ethical issues pertaining to the crash however there were a couple significant aspects that should not be overlooked as they had played a substantial role in the accident, as well as the ensuing damage that followed. Firstly, it was found that the engineer who was involved in the accident had sleep apnea, however we already know that. The bigger problem had been that he had to take a physical exam in order to be cleared to work. and he actually managed to pass the exam, even though he had this disorder which ended up flying over everyone’s head. This in turn has poked a massive hole in the credibility for physical examinations for personnel as it shows that examinations are not thorough enough considering that this was able to happen in the first place.

As such, many believe these examinations should be far more thorough, especially now due to media scrutiny, as it has become more and more apparent with the coverage of accidents on mass transport becoming more and more frequent. Secondly, it was found that the bumpers at the station were the original steel/concrete bumpers installed in 1907 as opposed to the more modern shock absorbing bumpers on most train stations, had the new bumpers been installed, the damages would have been far less severe especially on the passengers in the train, as the initial impact forces would be far less severe on both the station and the train itself.o fix their mistakes. This disaster at Hoboken station will hopefully make the NJ Transit decide that they need to spend more time and money into improving the safety and infrastructure of their trains. But as of right now, the commuters do not think that they are addressing their concerns or improving important safety features. 

 

It is unfortunate that these things happen, but necessary. Without tragedies like the Hoboken crash, and many other failures we've learned about in the semester; there would be no push for change and room for improvement. There is always a price we must pay. In the words of Margeret Heffernen; "For good ideas and true innovation, you need human interaction, conflict, argument, debate.

 

 

REFERENCES:

 

https://www.bloomberg.com/graphics/2017-nj-transit-complaints/

 

Dekker, S.W.A. 2011. Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems. Farnham: Ashgate Publishing Co

 

https://www.transit.dot.gov/ntd/data-product/2015-breakdowns

 

http://www.travelandleisure.com/travel-tips/travel-warnings/new-jersey-commuter-railroad

 

http://www.nj.com/traffic/index.ssf/2017/01/cost_of_rail_safety_system_on_nj_transit_balloons_to_320m.html

 

 

 

 

DRAFT: This module has unpublished changes.