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 Valentine’s 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 388-mile 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 Metrolink’s 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 Page 343 Metrolink engineer Robert M. Sanchez holding an Italian greyhound. Source: © AP Photo/Courtesy of Lilian Barber. 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 73 degrees. 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 train’s 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 locomotive’s 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 train’s 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 cab’s 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 sheriff’s deputy described the scene. “I saw locomotives engulfed in flames . . . and . . . I saw numerous people, maybe a dozen, walking in various means, I don’t 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. Page 344 THE INVESTIGATION 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 track’s 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 conductor’s 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 Metrolink’s 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 operator’s 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 compliance. 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 enforce. It’s almost impossible . . . [T]he engineer, first of all, is going to have the door locked. You’ve got to unlock the door to get up on it. He’s probably going to hear you coming— he or she, and, you know, it would be almost impossible to surprise somebody, you know, to inspect it . . . [O]f all the times I’ve gone up on a locomotive, I’ve 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 a locomotive. 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 fire-protected 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 NTSB’s “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 functions.13 Modern train control is technically complex, but the basic invention, electromechanical 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. CONGRESS ACTS 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. Page 346 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 benefit–cost 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 California’s 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 doesn’t 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? What’s your job? You’re sitting there saying you can’t tell them to do anything? . . . You have the power, you don’t want to do it, you’d 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 negligent.21 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. Page 347
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