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Friday, April 22, 2005 |
We have yet another yard switching fatality involving remote control, this time on the UP in Riverdale Utah on April 11. Anthony L. Petersen, a thirty-eight year old switchman with eight months of railroad experience was run over and killed. You can read two perspectives on this tragedy at the official UTU and BLE websites.
Our perspective is that this sadly illustrates the reality that such accidents don't always have a simple cause. Despite the carriers' committment to blaming the rule violator who is also often the victim, the web and chain of causality can often implicate others removed from the wreck by time and distance. An expert discusses these LEVELS of error:
Only rarely do accidents have just one cause, as US railroad investigatory practice has ordained for 174 years. They usually have multiple causes. Cause can be quite intricate, even regarding events not appearing intricate. Nevertheless, many, managers, researchers, consultants, and government regulators of railroads mistakenly attempt to learn the cause (a false singularity) of a rail accident.
For decades, we have known the investigator must, "forego the temptation to place the burden of accident prevention on the individual worker" (1). It is all too human to fashion a so-called human-factors outlook for blaming the scapegoat at the bottom of the chain of command and control. In US railroading, the tradition followed is blame it on the "pin puller" (switchman), etc. And it is an easier, less problematic task to find a simplistic, singular cause rather than an intricately interwoven one, often reaching up the chain of command. Railroads use adversarial investigations directed toward finding a rules violator so that he/she can be disciplined. Railroad managers customarily "fix" their employees instead of their behavior-engendering system.
The customary investigatory outlook focused on the behavior of one railroader, or the occurrence of one event, obstructs the search for systemic causes in the encompassing organizational and regulatory bodies of the industry. Causes include deeds of omission and commission. Causation might end in a work act but reaches back to failed, managerial practice, rules formulation, training, work organization, and engineering decisions, mostly under government regulation. An individual's error, then, might involve errors in the overarching system.
These LEVELS of error include Societal Error, Governmental Error (Legislative, Judicial and Regulatory), Organizational Error (Business and Labor Organization), and at the bottom of the wreck, Team and Individual Error.
So what might all this have to do with the killing of Brother Petersen? Did he, by violating some rule, kill himself? Did his Team kill him because they put him in a dangerous situation because they were in a hurry to finish their work? Why wasn't he wearing a box and why wasn't he in control of the movement and situated safely on the ground? Was the Team under some pressure to hurry as a result of things said or indicated by a Yardmaster or Trainmaster? Had they fallen behind because of yard congestion caused by lack of manpower and poor yardmastering? The accident took place at 0350, a time when most people are asleep in bed. Did fatigue play a role in Petersen's death? Were crews being worked to death in Riverdale, again because of UP's infamous mishandling of its manpower needs? It is reported that it was his second day on that particular assignment. Did his lack of familiarity with the yard or the work in question play a role in his death? Had he requested familiarization trips? Were they denied by management? It is reported that he had only 8 months of railroad experience. Is that enough to produce a switchman who can safely perform his duties when left unsupervised? Did the minimal training, both with and without the box, produce a risky worker? Is it possible that someone can "test well" on the rules and still not "get it" in the field? Did his trainers and local management "pass him" because they needed more men, even though he might have needed some more training? Does the "one size fits all" approach to training rails allow some risky prospects to slip through the cracks and into a dangeous rail yard? Did some UP officials in Omaha who decided to try out a neat job-killing technology on the cheap play a role in killing Petersen? Did a vice-president who determined that lack of rail experience is really not a factor in the ability to produce a safe RCO in two weeks kill him? Did the corporate elite who decided that training rails only takes a few months kill him? Did the labor organization that agreed to such an abreviated training program kill him? Or does a labor organization that decided to embrace a new and unproven technology for purely financial reasons deserve some responsibility? How about a Federal Regulatory Agency that allowed the ongoing RCO experiment in the first place, all without any binding constraints on the carriers because it didn't want to unduly burden them financially or otherwise? Did they play a part in killing Petersen? And societally, some communities were convinced that this RCO experiment was being handled incorrectly and passed resolutions and such, but in general there was little awareness or concern about anything that was going on in their back railyards. Can we hold them accountable for Petersen's death? Or, despite the inevitable conclusion of the official investigation that Brother Petersen killed himself by violating one or more rules, do all these pieces fall together into the real reason Petersen was sacrificed on the Altar of Profit and Progress.
Oh, we know, life itself is risky. It's a big lottery just taking the truck out onto the highway. It's risky to eat at MacDonalds or to eat the stuff they sell at the super market. And it's really risky to work on the railroad with or without the box. What's a person to do? Ignore these risks and hope for the best? Or think and talk about them and ask whether the risks we choose are understood and acceptible or whether they are unwarrented and imposed upon us by a cheap-labor conservative corporate feudalist religion of greed.
We think it is time to learn something from Brother Petersen's sacrifice and open our eyes.
1:13:21 PM 
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© Copyright 2005 The Usual Suspect.
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