The Metro Link Safety Failure Of Train Control Strategies Case Study Read the Metrolink case study as well as the Reuters article on train safety rules: Buffett May Benefit as Train Lobby Bids to Weaken Safety Rule. (Both articles attached) In your post, consider the following questions: What was the cause of the Metrolink accident and could it have been avoided?Is the high cost of train control justified by the likely safety gains for passengers?Is the money spent to regulate railroad safety being spent in the most efficient way to reduce the risks of death and injury in society?If you had been a lobbyist wishing to influence safety legislation after the crash, what would your strategy have been? Good and Evil on the Rails
As a child Robert M. Sanchez counted the cars on passing trains. One day when he was seven he
ran to an idling locomotive and the engineer took him into the wondrous machine, let him blow
the horn, and, unwittingly, set his course for life. As he grew up he often visited nearby railyards,
never losing his fascination with trains.
After high school he drove Greyhound buses for a time and then found work with Union
Pacific on a maintenance crew. After several years he worked his way up, fulfilling his dream of
becoming an engineer. Soon Amtrak hired him. He and his partner, a waiter, bought a home near
Los Angeles. Neighbors described Sanchez as relentlessly cheerful, buoyant, and passionate
about trains. Yet trouble was there too. He was caught shoplifting at Costco, pleaded guilty, and
served 90 days in jail on weekends. He argued with his partner and suggested they break up. On
February 14, 2003, his partner hung himself in their garage, leaving a note that read: Rob, Happy
Valentines Day. I love you.1
Two years later Sanchez became an engineer for Metrolink, a commuter rail system crossing
six Southern California counties. Metrolink carries about 40,000 passengers a day on a busy 388mile track network shared with freight traffic. He loved his job though he worked a tiring split
shift. Soon he bought a modest suburban house where he lived with four miniature greyhounds.
Again, neighbors described him as cheerful, spirited, and exhilarated by railroading, but some
saw him as a recluse who kept to himself and avoided revealing his past. He abided with a dirt
yard that stood out in a neighborhood of tended landscapes.2
Although friends said Sanchez found joy in his work, there were a few difficulties. He
received five informal discipline letters for absences and failure to follow rules. Twice he was
counseled orally about use of his cell phone while on duty. In July 2008 a suicidal man
sidestepped a crossing arm and ran in front of the train he was operating. Under Metrolinks
policy he took some days off before returning to work, but, according to his family, he was forced
to go back before his emotional recovery was complete.3
Metrolink engineer Robert M. Sanchez holding an Italian greyhound. Source: © AP Photo/Courtesy of Lilian
FRIDAY, SEPTEMBER 12, 2008
On this day, Robert Sanchez was up before dawn. He reported at 5:30 a.m. and worked four
hours, rested four hours, then returned to work in the afternoon. At 3:03 p.m. he took train 111, a
diesel-electric locomotive and three passenger cars, on a commuter route out of Union Station.
After five stops he approached the Chatsworth station 33 miles northwest, passing a solid yellow
light indicating he should be prepared to stop at the next signal. He failed to radio the dispatcher
and call it out as required. It was a beautiful day there with clear skies, calm winds, and a mild
After stopping for 57 seconds the train departed the station, a random assembly of 225 souls
with perhaps the most troubled in the lead. At exactly 4:20:07 p.m. Sanchez shifted the throttle
from the idle position to position 2 and released the trains air brakes. As it moved, he pushed the
throttle to its maximum 8 position. Rapidly, the train increased speed to 42 mph. At 4:20:20 he
sounded the locomotives bell and horn for the Devonshire Road crossing.4
At 4:21:03 he received a short text message from a teenage rail fan: I would like that too. We
already need to meet 796. That would be best. This was about a plan for Sanchez to sneak him
aboard the locomotive later that day and let him take the controls for fun. At 4:21:23 Sanchez
again activated the bell and horn for the Chatsworth Street crossing. By 4:21:35 the trains speed
was 54 mph and he moved the throttle back to position 4 and braked, slowing it to 44 mph in
preparation for a curve. At 4:21:56 the train passed a red signal light ahead of the curve. It was a
command to stop. Sanchez failed to radio in the signal and did not stop.
At 4:22:01 Sanchez sent a text in reply to the teenager: yea . . . usually @ north camarillo. At
4:22:02 the train passed over a power switch turned to move a local freight train coming in the
opposite direction off on a siding.
The freight train was Union Pacific LOF65-12 consisting of two locomotives and 17 cars. It
entered the curve eastbound at 41 mph as Sanchez came on at 43 mph from the west. Closing at
a combined 84 mph, each locomotive became visible to the engineer in the other only when they
were 540 feet apart and four to five seconds from impact. In that instant the Union Pacific engineer
and the conductor, who was also in the cab, saw the Metrolink locomotive. The engineer hit an
emergency brake and started to run out the cabs rear door. Seeing there was too little time he
just stood there and watched it happen in disbelief.5 The conductor froze on his feet, uttering
an epithet. In the other locomotive, Sanchez did nothing with the controls.
At 4:22:23 the trains collided. The lead Union Pacific locomotive crushed Sanchez before
pushing the massive bulk of his locomotive back 52 feet into the first coach. The compression
killed 23 passengers. Another person died in the second coach. A sheriffs deputy described the
scene. I saw locomotives engulfed in flames . . . and . . . I saw numerous people, maybe a dozen,
walking in various means, I dont know, delusioned, like they were zombies waking with various
types of injuries with their hands out and saying help . . .6 Rescue workers needed four hours to
extricate all the victims from wreckage. Hospitals took in 102 injured including the engineer and
conductor from the freight train.
The National Transportation Safety Board (NTSB) was called in. The NTSB is a small,
independent federal agency established by Congress in 1967 to investigate transportation
accidents and make safety recommendations. It did a detailed analysis of the collision,
interviewing witnesses, holding hearings, and examining physical evidence such as the signal
switch wiring and even fasteners on the tracks wooden crossties.
An autopsy found that Sanchez had adult-onset diabetes, high blood pressure, and an
enlarged heart. He met the clinical definition of obesity. And he was HIV positive. His use of
prescription drugs kept these conditions under control. The Union Pacific conductors blood and
urine tested positive for marijuana use, though this was not relevant to the cause of the accident.
The investigation also focused on management. Metrolink is organized as a regional
association with a governing board of representatives from five Southern California counties. It
was formed in 1992 to improve mobility and reduce traffic congestion in densely populated areas.
Most of its operations are outsourced. Sanchez was hired and supervised by Connex, the
subsidiary of a French corporation that ran Metrolinks trains under a contract worth about $25
million a year.
Under the contract Metrolink retained overall responsibility for its operations. As one top
Connex manager noted, We run the railroad the way they want it run. 7 However, much was
delegated, including the supervision of train crews. Connex conducted the efficiency tests
required of every railroad.8 These tests are done by supervisors who observe trains, monitor radio
traffic, and analyze data from recorders in locomotives to check rules compliance. For example,
they use stopwatches to make sure engineers blow horns for 15 seconds before entering a street
crossing. They use radar guns to check train speeds. They stop trains for surprise inspections.
Connex supervisors performed about 1,000 such tests monthly. During his three years with
Metrolink Sanchez had only a few failures on them. In 2006, when a rule against cell phone use
on duty went into effect, a safety manager arranged for someone to call Sanchez number, then
stopped his train and boarded the locomotive. As they were talking, Sanchez phone rang. The
phone was not supposed to be in the operators compartment or turned on, but it was stowed
away in a bag and Sanchez said he had forgotten about it. The supervisor accepted this and
simply counseled him about the policy. No more calls were made to his phone to test his
In 2007 he twice was cited for failing to call out a wayside signal. Engineers are supposed to
radio the Metrolink operations center to acknowledge each lighted signal they encounter. Still,
his supervisor said Sanchez was frequently tested on calling signals and his performance was
above average.9 Earlier that year Sanchez also got a written warning for neglecting to light a
marker at the end of his train. And about a month before the collision a conductor saw him using
a cell phone as his train was ready to leave a station. Sanchez told him he knew he should put the
phone away and did. The conductor reported this to their Connex supervisor, who spoke to
Sanchez again about the policy and did two observations of him in the next two weeks. He was
confident that Sanchez understood the policy. However, the supervisor said it was hard to
Its almost impossible . . . [T]he engineer, first of all, is going to have the door locked. Youve got to unlock the
door to get up on it. Hes probably going to hear you cominghe or she, and, you know, it would be almost
impossible to surprise somebody, you know, to inspect it . . . [O]f all the times Ive gone up on a locomotive,
Ive never seen anybody with a cell phone or talking on a cell phone.10
In themselves, these incidents on Sanchez record were not damning. The Connex safety
manager had a subjective faith in him. [He] was a competent engineer, he told investigators,
[a]nd I felt comfortable putting people with him.11 Several weeks before his final shift Sanchez
even got an award for safety and rules compliance.
However, his behavior on the day of the accident showed brazen deceit and disrespect for
rules. He failed to call out two signals. And Verizon Wireless records showed he made four phone
calls, sent 21 text messages, and received 21 text messages while operating the train. It was
habitual behavior. On each of seven working days preceding the accident he had made calls and
sent and received between 30 and 125 text messages while operating trains.12 Most of the texting
was with teenage rail fans. Interviews revealed he had once before let a teenager sneak on to run
In its accident report the NTSB stated the probable cause of the collision as Sanchez
inattention to the red signal light because texting in violation of company rules distracted him. It
made one new recommendation, that railroads put audio and video devices in locomotive cabs
to monitor train crews. It repeated a previous recommendation for installing a crash- and fireprotected cab voice recorder similar to those in commercial airliners. And it noted that an
automatic system called positive train control would have intervened to prevent the collision by
taking control of the train when Sanchez failed to stop at the red signal.
POSITIVE TRAIN CONTROL
Positive train control is an old idea in railroading. It had been on the NTSBs Most Wanted List
of Transportation Safety Improvements for 18 years at the time of the accident. Now, thanks to
Robert Sanchez, it would become a reality. Briefly explained, it is an interconnected network of
digital data and controls. It allows remote operators to take control of trains from on-board
engineers if necessary. It includes these basic elements.
Global positioning system receivers on trains to continuously track movement.
Computers on trains that record data and send information to displays in locomotive cabs about
train position, speed, length, and weight; route speed limits; actual and recommended throttle
and brake settings; sensor readings on cars; signal and switch settings; and more.
Wayside devices that monitor signals, switches, and track alignment, and can detect overheated
brakes, cracked wheels, rock slides, and other problems.
Wireless interfaces on throttle and brake controls that allow remote control.
Computers and displays in railroad operations centers that show the schedule, position, speed,
and control settings of each train in the network and allow remote command of train and track
Modern train control is technically complex, but the basic invention, electro-mechanical
automatic braking, came around 1900. In 1920 the Interstate Commerce Commission (ICC)
ordered 49 railroads to install it on passenger lines to reduce accidents and fatalities. Though
effective, the systems were very expensive to put in and maintain.
When interstate highways spread in the 1950s, rail traffic faced more competition from
trucking. Revenues fell, tracks were abandoned, railroads failed or merged, and the ICC let
companies discard the controls. After that, human error regularly led to avoidable fatalities from
train collisions, overspeed derailments, and runaway locomotives in work zones. Periodic
headline accidents that killed passengers led to regular calls for reinstating automatic controls.
However, little was done because the railroads argued it was unaffordable.
When the National Transportation Safety Board placed positive train controls on its Most
Wanted list in 1990 it revived the issue. Congress considered action, but retreated when the
Federal Railroad Administration (FRA) did a study showing that the cost of controls far
outweighed safety benefits.14 The FRA is part of the Department of Transportation. As an
executive branch agency its administrator is nominated by the president and approved by the
Senate and, when appointed, reports to the Secretary of Transportation. Congress created the
agency in 1966 to regulate railroad safety. It also administers federal programs that support
railroads and promote passenger service, giving it close ties with the industry it regulates. Most
of its 900 employees have worked for railroads.
After the early 1990s there were short bouts of Congressional interest in train controls after
major rail accidents. In 2003 Congress asked the FRA for an updated benefitcost study. It showed
that the costs still far outweighed safety benefits.15 In 2005 the agency issued a rule to encourage
voluntary use of train controls.16 Lacking a mandate, railroads installed automatic systems on
only about 4,000 track miles, most in the Northeast.
A few legislators remained interested in train controls. When the Metrolink crash occurred,
there were two moribund bills in Congress, a House bill requiring controls on several high-risk
routes and a Senate bill seeking only further study. Neither was headed to passage because of
opposition from railroad lobbyists.
The Metrolink fatalities mobilized Californias two Democratic senators, Dianne Feinstein
and Barbara Boxer, who zoomed in like superheroes on a mission. Within a week they introduced
an amendment to the House bill, which had already passed, ordering railroads to install positive
train control. In remarks on the Senate floor, Senator Feinstein grew irate and accused the
railroads of criminal negligence.
The accident happened because of a resistance in the railroad community in America to utilizing existing
technology to produce a fail-safe control of trains . . . Over the years the railroads resisted, saying these systems
are too expensive. Well, how expensive is the loss of human life? The cost of any system doesnt come close to
the cost of the lives that were lost this past Friday.17
A week later she and Senator Boxer invited Joseph H. Boardman, administrator of the FRA,
to a public hearing. Senator Feinstein opened the hearing by saying she was upset with lobbying
behind the scenes to prevent an early date for installation of train controls. Boardman explained
to the two senators why progress has not been faster, namely because of limited availability
of needed radio spectrum, concerns about interoperability, and braking algorithms that need
refinement.18 These technicalities must have sounded like excuses to Senator Boxer and they
drew a sharp rebuke.
What powers do you have? Whats your job? Youre sitting there saying you cant tell them to do anything? . . .
You have the power, you dont want to do it, youd rather work for the railroads.19
After the hearing Senator Feinstein called the FRA an old boys club. I think they sit down
and talk to the railroads, she said. I think they do what the railroads want.20 In floor remarks
she tried to stir her Senate colleagues to action with a moral argument.
When we know there is global positioning that can be in place to shut down the freight train and the passenger
train before they run into each other and we do nothing about it, then I believe this body is also culpable and
This idea echoes Aristotle, who held that ethical decisions are a matter of choice and only
ignorance of facts or lack of freedom to act excuses a person from choosing the ethical
action.22 Senator Feinstein deprived the senators of either excuse. But many Senate Republicans
were unmoved and still tried to stop the bill, believing it imposed a net economic burden on
society. Their effort to thwart its passage with a filibuster was defeated, and on October 1, 2008,
just 19 days after the Metrolink accident, the Rail Safety Improvement Act of 2008 became
law.23 The roll call was 74 to 24. Every Democrat voted for it and all the nay votes were
Republicans. These are the main provisions of the 123-page statute.
Sen. Dianne Feinstein (D-California) opens the hearing on positive train controls on September 23, 2008. At
right is Sen. Barbara Boxer (D-California). Source: © AP Photo/Manuel Balce Ceneta.
Mandatory installation by 2015 of positive train control on rail lines shared by freight and
passenger trains, on main lines carrying more than 5 million tons of freight yearly, and on
any stretch of track carrying substances such as ammonia and chlorine that pose toxic
Rules designed to prevent crew fatigue, including prohibition of train crews working more than
12 hours a day or 266 hours a month.
A long list of new mandates for the Federal Railroad Administration including certifying
conductors, monitoring locomotive radio traffic, and studying the safety of antique
locomotives used for rides at railroad museums.
Measures to improve safety at railroadhighway crossings.
Assistance to families of victims of passenger train accidents.
A program of annual $50 million grants to railroads for safety improvements.
REGULATORS GO TO WORK
Like many laws passed by Congress, the Rail Safety Improvement Act is a mixture of specifics
and generalities. It was very precise in dictating work-hour rules for train crews under varying
circumstances, even prohibiting companies from telephoning or paging crew members at home
during mandatory 10-hour rest periods. Yet it also set broad new requirements such as positive
train control that left much to the discretion of the Federal Railroad Administration. In fact, it
gave the agency so much to do it authorized hiring 200 new employees. Quickly, the agency went
Within a week of the bills passage it issued an emergency order prohibiting use of wireless
electronic devices in locomotive cabs and elsewhere on or near operating trains. 24 It cited seven
accidents besides the Metrolink collision where cell phone use distracted engineers. Two led to
fatalities. It also listed examples of unsafe behavior observed by its staff. Some of the stories were
An FRA deputy regional administrator was conducting an i…
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