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Crew Performance

Crew Performance. Train P-22 crew failed to reline a main line switch. Train 192 diverted onto industrial track . Throughout the Day. The crew worked at various industries.

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Crew Performance

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  1. Crew Performance • Train P-22 crew failed to reline a main line switch. • Train 192 diverted onto industrial track.

  2. Throughout the Day • The crew worked at various industries. • They had established a pattern of arriving at an industry, opening switches, performing work, returning to the main line and relining the main line switch. • After completing their work, they repeated this routine at the next location.

  3. At Avondale Mills • Crew had only 50 minutes to complete their work • Conductor failed to conduct a job briefing

  4. An error of omission • Performed tasks in a direct, linear succession • Regular task sequence interrupted • Change in plans created new sequence • Crew accomplished their primary objective • Crew directed their attention to a new task • Banner not visible

  5. Why the switch was not relined • Functionally isolated • Crew rushing to complete their duties • Crew focused on the next task • Switch banner not visible

  6. FRA postaccident actions • Safety Advisory 2005-01 (1/10/2005) • Emergency Order 24 (10/19/2005) • Requires what the previous safety advisory had recommended • Demonstrated to to be of questionable effectiveness

  7. Alternative approaches: possible ways to address the issue • Strobe like device • Electronic technology • Additional ways to capture employee’s attention

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