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Were portions of the Chatsworth train head-on investigation botched? [1]

['This Content Is Not Subject To Review Daily Kos Staff Prior To Publication.']

Date: 2023-09-09  

It seems like just yesterday that one of America’s deadliest train-on-train collisions happened. This one occurring on September 12, 2008 — fifteen years ago — is one people having a connection to it won’t soon forget.

The site of the crash was located slightly over a mile from the Chatsworth, California Metrolink-served passenger train station. All told, a total of 25 onboard passengers and a locomotive engineer - this person that fateful late-summer day piloting one of the two involved trains (Metrolink Train #111) - perished. One-hundred-thirty-five others sustained injuries of varying degree - light, moderate and critical, alike. This qualifies as one of America’s deadliest train mishaps.

One can always speculate, but had the platform architecture of what is today known as positive train control or PTC incorporating in it a functioning collision-avoidance component been in use and operational in that track territory on that fateful afternoon, this truly tragic event likely would not have happened.

Naturally, an investigation into cause(s) of the incident was initiated. After all was said and done and the investigation concluded, a detailed accident report was issued. Subsequent to my cover-to-cover fine-toothed-combed report perusal, I had questions and concerns.

Those questions and concerns are laid out here and are subdivided into two categories: inconsistencies and missed opportunities. What my analysis proposes to do is shed additional light on some of what during the investigation was uncovered or discovered and how, if in replicating operating protocols exactly as they existed on the day of the collision, the crash findings, or, at least, four, anyway, may have led to different cause-of-accident conclusions being reached in those four instances.

My interest and background

Really briefly, being that I had once worked in the area of railroad signaling, I wanted to learn as much as I could about this particular event and its possible or probable causes. I researched this matter exhaustively. I also conversed with many people, one of whom was the mother of one of the critically injured crash victims. My hope in corresponding with this person was that additional perspective would be provided. I believe that it was.

Once the railroad accident report was publicly released and I was able to read it, I figuratively went over it with a fine-toothed comb. I characterize my findings as quite illuminating.

Missed opportunity 1

Finding 5. “Physical evidence, documentary and recorded data, and post accident signal examination and testing confirm that the westbound signal at Control Point Topanga was displaying a red aspect at the time Metrolink train 111 departed Chatsworth station and as it approached and passed Control Point Topanga, and had the engineer complied with this signal indication, the accident would not have occurred” (NTSB Railroad Accident Report RAR-10/01, Jan. 21, 2010, page 65).

From the section of the report: “Review of Recorded Signal Data (page 25), this lis what is presented:

“Downloaded data from Digicon event logs at the Metrolink dispatching center and signal event recorders in the field indicate that, at the time of the accident, the westbound signal at CP Topanga was displaying a red aspect (stop indication) and the dispatcher’s stacked request to clear this signal was waiting in the queue in the Digicon dispatching system” (page 25).

“Moreover, “The Metrolink dispatch center aligned the route as it was at the time of the accident, and investigators used rolling shunts to simulate the movements of Metrolink train 111 and the Leesdale Local” (page 39).

“At the time of the accident” is a vague notion. Worded this way, this does not address what downloaded data from the Digicon event logs at the Metrolink dispatching center and signal event recorders in the field indicated between the time Metrolink train 111 pulled into the Chatsworth station to the time up to and including its approach to the westbound Topanga signal prior to passing the signal. Metrolink train 111 passed the westbound CP Topanga signal at 4:21:56 p.m. Pacific Daylight Time.

Next, it is known what the aspects and indications of eastbound intermediate signal 4426 were immediately prior to UP train LOF65-12 passing it. The GRS sentinel signals were displaying yellow-over-yellow aspects indicating “approach diverging.” (See footnote 14, page 5). However, it was never stated through event recorder data retrieval what the colors of the displayed signals were at the eastbound Control Point Topanga signal heads, to which there are two: Signal head A and signal head B. (The two signal heads can be seen in Figure 8 on page 26 in the left center of the photo to the left of the mainline track).

During signal testing, “With the eastbound signal at Topanga displaying clear, investigators applied battery power to the green signal lamp of the westbound signal” (page 39).

“As an additional test, investigators had the CP Topanga switch aligned for eastbound movement into the siding and locked. They then initiated a request to clear the Topanga westbound signal. This test was performed once with the eastbound signal displaying clear and again with the signal displaying stop” (page 40).

What isn’t known is what the color the eastbound CP Topanga signal aspect in signal head B (the corresponding signal head governing the train movement into the Topanga siding) was immediately prior to Metrolink train 111 passing the westbound CP Topanga signal mast.

Inconsistencies 1, 2 and 3

Finding 6. “Eyewitness reports of seeing a green aspect from the Chatsworth station are contrary to the other evidence; postaccident testing and research show that witnesses could not have reliably seen the red aspect that the Control Point Topanga signal was displaying as train 111 departed the station because of a combination of extreme distance to the signal (more than 1 mile), lighting conditions at the time, and limitations of the human visual system” (page 65).

“In postaccident interviews, the train 111 conductor and three other individuals (two rail fans and a security guard) who were on the Chatsworth station platform while the train served the station stated that had seen the CP Topanga signal as train 111 pulled out of the station and that the signal was displaying a green aspect. Had this signal been displaying green, the engineer’s actions after the train departed the station would have been appropriate, at least until he was close enough to the CP Topanga switch to see that the switch was aligned against his train. Had he realized that he was about to run through the switch, he would doubtless have taken action to stop the train even if the signal had been green. But he took no action in his approach to the switch, while running through it, or immediately afterward” (page 50).

(For all I know, the signal testing might have actually taken place prior to eyewitness testimony claiming the signal aspect of westbound Control Point Topanga was green).

Based on information presented, unknown is if Robert Sanchez noticed the signal aspect at CP Topanga on his approach to the westbound CP Topanga signal or the position of the switch points located roughly 337 feet west of that. Also unknown was why a reduction in speed of approximately 11 mph was made from a maximum train 111 speed of 54 mph after departing the Chatsworth station to about 43 mph when the collision occurred. Meanwhile, known is that for two crossings, horn and bell applications were initiated, throttle adjustments were made and brake pipe reduction was initiated.

Finding 7. “The signal and traffic control systems worked as designed on the day of the collision, and the dispatcher’s ‘stacking’ of train routes played no role in the accident” (page 65).

“The Metrolink dispatch center aligned the route as it was at the time of the accident and investigators used rolling shunts to simulate the movements of Metrolink train 111 and the Leesdale Local. Signal personnel positioned at CP Davis, intermediate signal 4426, at the east- and westbound signals at CP Topanga, at intermediate signal 4451, and at CP Bernson confirmed that the signal system functioned as designed and intended” (page 39).

Reiterating, “at the time of the accident” is a vague notion.

Meanwhile, Footnote number 46 on the same page reads: “On the day of the accident, the dispatcher had stacked the route for the westbound movement; on the day of the testing, the westbound route requests were not stacked.”

Therefore, one is left to question the reason or reasons for the “stacked” versus “non-stacked” signal conditions. At the very least, there is confusion regarding what is meant when it is stated: “The Metrolink dispatch center aligned the route as it was at the time of the accident…” and what is meant when it is stated: “On the day of the accident, the dispatcher had stacked the route for the westbound movement; on the day of the testing, the westbound route requests were not stacked.” The two statements appear to be contradictory.

As for Finding 7 (“The signal and traffic control systems worked as designed on the day of the collision, and dispatcher’s ‘stacking’ of train routes played no role in the accident.”), well, it is what it is.

Finding 8. “The engineer of train 111 was actively, if intermittently, using his wireless device shortly after his train departed Chatsworth station, and his text messaging activity during this time compromised his ability to observe and appropriately respond to the stop signal at Control Point Topanga.”

There is a question, however, as to when text-message number seven sent from Person A’s wireless device was received by Robert Sanchez’s wireless device. Two different times were presented in the NTSB report.

In one part of the report, it is documented that the seventh such text message received on Sanchez’s wireless device was received at 4:21:03 p.m.

“Verizon Wireless records of calls and text messages to and from the engineer’s personal cell phone/wireless device showed that while the engineer was en route from the maintenance facility to Union Station he received a text message from an individual who will be referred to in this report as ‘Person A.’ This was the first of seven text messages Person A transmitted to the engineer from the time train 111 departed the maintenance facility until the accident” (page 2).

“At 4:21:03 p.m., Verizon records show that the engineer the seventh text message from Person A” (page 7).

Then, in another part of the report, it is documented that “The last message received by the engineer from Person A arrived at the engineer’s wireless device at 4:20:57, about the time train 111 was accelerating out of Chatsworth station” (page 35).

(Based on information in the NTSB report, when, exactly, the sixth text message received on Sanchez’s cell phone/wireless device, sent by Person A, was, only that it was received at about the time train 111 was leaving the Chatsworth station).

“Because wireless network records regarding ‘sent’ times are less precise than those regarding ‘received’ times, it cannot be known with certainty at what time the engineer pressed the ‘send’ button on his wireless device to transmit his last message. But the content of the message clearly shows that it was in response to the previous message, which he had received just as the train was pulling out of the station” (page 54).

Incontrovertible was that Sanchez was engaged in text messaging activity up to 22 seconds prior to the point of impact.

My summation

While I cannot prove otherwise, locomotive engineer Robert Sanchez, based on the evidence presented in the report of his actions on September 12, 2008 while at the controls of the locomotive in question while in the cab, upon him pulling his train out of the Chatsworth station, I feel that after reading this report in full and considering all of the report information presented, he, in my opinion, likely was somewhat negligent in carrying out his assigned responsibilities that day.

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[1] Url: https://www.dailykos.com/stories/2023/9/9/2192407/-Were-portions-of-the-Chatsworth-train-head-on-investigation-botched

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