> The fact that NTSB investigators would even include this tidbit of information in
> an ACCIDENT REPORT speaks volumes of where we're at in the railroad industry today

Yes, it does. But not the way you imply.

Just because a "tidbit" is included in a full report of the NTSB, hardly means that any investigator thought it relevant to the cause of the incident. All discovered information must be included in the final report; to maintain total transparency and to assure that a complete and full context surrounding the incident, is well understood.

Granted - that context is often not heeded by managements! Especially in the realm of employee fatigue and distractability, as a cause of accident. But with full context supplied in accident reports, managements are left with utterly no righteous excuse for continuing practices in this area, that are thus well known to contribute to accidents. I would think it important to leave one's tormentors without excuse!

Having been assigned numerous times to investigation teams, I can tell you that all pieces of data surrounding an incident, that can be discovered, relevant or not; are searched out, documented, and pursued to wherever they lead. Most lead nowhere! They are nevertheless recorded, cataloged, and left for possible additional review later - and not one left out of the full report, relevant or not.

At some point in an incident investigation, one or more "Hot Spots" in this otherwise boring mass of data, will usually appear. These represent areas where deeper research will then be focused. This is where I am usually assigned, digging deep into the forensic evidence, until we can propose a hypothesis that rationally and consistently explains all the available evidence - beyond reasonable doubt.

Sometimes, this can draw in pieces of data previously thought irrelevant, but usually most of it stays irrelevant. Other times, especially when very subtle causes of accident are involved (such as at the WMATA accident), it is only a seemingly unimportant impropriety in maintenance records or employee conduct, that gives a meaningful clue as to what went wrong.

It is not that incorrect record keeping or some employee lapse to be yawned over, caused the accident; but that in the process of discovering those facts, real clues will often be found; which can then be pursued down to the laboratory level if necessary, yielding the real causes.

In the case of WMATA, the cause was failure of the safety equipment itself (you know - the likes of ACS, ATC, ATP, PTS, etc). But why and how it failed had to be discovered - just as it is also critical to discover how humans goof it up too. As I've said a million times before - it makes no difference whether human error causes an accident or a machine error causes it - people are going to be just as dead!

Where we are in the industry now, is that the true cause of every accident that involves public safety - even minor ones; is diligently pursued in the doggedly determined effort, to learn how to prevent them. And that matters more that anything else. Even more than yours or my jobs!

And that is right where we ought to be!

OPB