Yes, the FRA does have a Confidential Close Call Reporting System called
C3RS. It will only work if a railroad chooses to get involved in the program. As far as I know, the Strasburg RR is the only tourist railroad that participates in C3RS.
From my point of view, and as discussed in a thread below, the railroad industry safety culture is a "blame" culture, intent on finding blame after a incident, rather than finding the root cause of the incident and resolving the problem. In almost all cases resulting in a serious incident, there were plenty of leading indicators that were giving signs that procedures were not being followed, assuming there were any written procedures to begin with. Even with written procedures, there is a risk of "practical drift" where procedures are no longer followed completely as either management or employees have found shortcuts that get the job done quicker and easier. This will eventually result in a incident or failure. Practical drift is defined as the unintentional adaptation of routine behaviors from written procedure.
I find with many tourist operations, there are no specific or written procedures and training is poor regarding basic mechanical and operating maintenance. For example, conducting a boiler wash as required by Part 230. Part or this requirement is the removal and inspection of
all washout plugs, not just the ones that are easier to get to. Has the employee/volunteer had any basic training on how a tapered washout plug works and how it tightens in the boiler? Do they know what to look for when inspecting the threads and the threads in the boiler? Do they understand how to appropriately tighten the plug after inspection or how to handle if the plug is leaking under steam? Does the railroad have basic written procedures regarding how to conduct a boiler wash and what is expected too determine the boiler is clean, free of defects and ready to return to service?
There are still a few of us around since the tragic incident at Gettysburg in 1995 (NTSB report attached), but may have forgotten the lessons learned to make sure something like that never happens again. The current and next generation needs to understand that whether it is the locomotives, track, cars or the humans involved, there is always a potential risk. How each individual operation or the industry wants to handle or develop standards, training and then develop a basic "System Safety Plan" to continually monitor all this is up to them. Another "Gettysburg" incident on one operation may spell the end for the industry as a whole.
Off my Soap Box
MD Ramsey
Gettysburg NTSB Report, Boiler Explosion.pdf
Edited 1 time(s). Last edit at 06/09/2021 09:30AM by MD Ramsey.
