National Railroading Safety (Amtrak & Host Railroads)

I find this article interesting:

http://www.duluthnewstribune.com/news/4 ... e-superior" onclick="window.open(this.href);return false;

It is about the findings of the grounding in Lake Superior of M/V Roger Blough, one of the bigger ships on the lakes. Essentially, the US Coast Guard found that the crew, up to and very much including the skipper, were complacent. The USCG notes that they frequently rotate people in order to prevent complacency. I find that concept very interesting and not widely known in heavy industry. Recently I co-wrote an article on safety culture in steel mills with a top ArcelorMittal safety official, and we discussed how personnel rotation could be beneficial to prevent complacency.

Although I am not a railroader, I deal with equipment using very similar technology and personnel with similar skill sets. The wheels, rails, bearings, brakes, etc... on heavy cranes in shipyard and steel mills are all similar if not identical to railroads, and the operators, inspectors, and repairmen could be swapped with minimal training. I find that complacency is something we don't even think about many times. The same guy inspects the same wheels on the same equipment every day. Catastrophic cracks like I assume happened to the drawbar pin on Acela don't happen overnight. See the image below:



I still remember the first time I saw a catastrophic crack like this. The smooth crack is a long time developing, while the rough surface is where the actual catastrophic crack happened when the remaining metal was materially overloaded trying to handle forces designed for 100% of the steel rather than the 60-80% remaining.

The long and short is that there are really no catastrophic cracks. There are slow unobserved cracks that keep growing until they pop.

This is why OSHA requires daily shift inspections on lots of heavy equipment, so operators can report any funny-sounding or funny-looking equipment and pull it from service. Unfortunately, the same guy looks at the same stuff every day for 2+ years and gets complacent, which is why I suggest operators swap jobs and/or do a daily shift inspection on someone else's equipment.

That's why this Acela breakapart gets under my skin. Someone could've been seriously hurt and it strike me as avoidable.

Tadman, i am glad someone else can see the grave nature of this incident in particular. Amtrak does not provide specific heavy maintenance procedures like boroscoping and metal fatigue. This coupling system has probably been the same in use since manufactured.

Well, if nothing else those coupler pins look cheap enough where you could replace them all pretty inexpensively as opposed to waiting for the next one to break.

Safetee wrote:Well, if nothing else those coupler pins look cheap enough where you could replace them all pretty inexpensively as opposed to waiting for the next one to break.

Yeah, it’s a big hunk of steel, though it might be a specific alloy and certainly has a specific treatment method after manufacture (milling, heat treatment/stress relief.) From what I know about metallurgy, high-stress parts like this ought to be visually inspected on the regular, with dye penetration and Magnaflux tests at specified periods or whenever there is a high-stress incident like a collision or hard pull.

In the end, the pin did what it was designed to do: fail (if it did fail, rather than just falling out or something) so the drawbars, coupler pockets and frames don’t. This is a major maintenance issue though, and the HST Barns ought to be on notice.

Hope this isn't too OT
I remember an NEC signal failure in summer 2015. From what I could observe being in a MARC train for over an hour, it seemed like all trains on that portion south of Baltimore were held to a very low speed limit, like 25mph. Why isn't what's good for the goose, good for the gander? Wouldn't a blanket policy of "if automatic signals are down - especially on a host railroad - assume the worst and that any switch could be mislined or any train in an unexpected place" be the best policy?

mtuandrew wrote:

Safetee wrote:Well, if nothing else those coupler pins look cheap enough where you could replace them all pretty inexpensively as opposed to waiting for the next one to break.

Yeah, it’s a big hunk of steel, though it might be a specific alloy and certainly has a specific treatment method after manufacture (milling, heat treatment/stress relief.) From what I know about metallurgy, high-stress parts like this ought to be visually inspected on the regular, with dye penetration and Magnaflux tests at specified periods or whenever there is a high-stress incident like a collision or hard pull.

In the end, the pin did what it was designed to do: fail (if it did fail, rather than just falling out or something) so the drawbars, coupler pockets and frames don’t. This is a major maintenance issue though, and the HST Barns ought to be on notice.

Completely agree. If they don't regularly inspect these couplings, that is a huge problem.

I believe our friend Dutchrailnut once mentioned that the reason couplers are no longer allowed to be painted (by FRA perhaps?) was so it is easier to do NDT testing such as Magnaflux. Obviously somebody in the rail safety arena knows these should be part of an inspection routine. This is not rocket science.

dt_rt40 wrote:I remember an NEC signal failure in summer 2015. From what I could observe being in a MARC train for over an hour, it seemed like all trains on that portion south of Baltimore were held to a very low speed limit, like 25mph. Why isn't what's good for the goose, good for the gander? Wouldn't a blanket policy of "if automatic signals are down - especially on a host railroad - assume the worst and that any switch could be mislined or any train in an unexpected place" be the best policy?

In that case the outage was likely not planned. The only way to move traffic would have been at restricted speed, 20 MPH or less ready to stop within half of sight distance. Restricted speed is better than all stop.

In the case of a planned outage - a signal suspension - the rules are different. CSX stationed people along the railroad to report the position of each switch so the trains did not have to proceed at a speed prepared to stop, They relied on the conductor at the site to tell them (through the dispatcher) that the switch was aligned correctly.

They could have run all trains at restricted speed. But it is hard to get all the traffic through when all of the trains are crawling. Especially on a single track line. So they relied on the tried and true procedures for "signal suspension".

dt_rt40 wrote:Hope this isn't too OT
I remember an NEC signal failure in summer 2015. From what I could observe being in a MARC train for over an hour, it seemed like all trains on that portion south of Baltimore were held to a very low speed limit, like 25mph. Why isn't what's good for the goose, good for the gander? Wouldn't a blanket policy of "if automatic signals are down - especially on a host railroad - assume the worst and that any switch could be mislined or any train in an unexpected place" be the best policy?

Yes, what a pain it was.
The maximum speed is around 20mph during an ABS failure, approaching almost every break in the rail prepared to stop. That is Mark 1 railroading on the NEC.
Mark 2 railroading is a Form-D between specific points.This allows for FRA regulated speed of 59mph(passenger) between points-one train at a time.Very inconvenient for dispatchers as they must do a lot of train specific writing.Also, as with Mark 1, routes must be inspected at breaks in the rail to ensure you do not overrun the limits of authority.
Mark 3 railroading is your basic wayside signal system without cab signals that allows for FRA regulated speed of 79mph.
Mark 4 railroading is Wayside+Cabsignalling for FRA regulated speed of 125mph.
Mark 5 railroading is Wayside+Cabsignalling+Speed Enforcement for FRA regulated speed of 125+mph

Now of course this is a very basic summary of NORAC operations on the NEC and I could go more in depth, but you can see how if just a cab signal failure occurs, significant delays can be had.

It may be time for the major railroads to collectively create a single operating rules book to rule them all.

BlendedBreak wrote:It may be time for the major railroads to collectively create a single operating rules book to rule them all.

Sure. Change all the NORAC roads to GCOR. Do you prefer speed signalling or route signalling? The railroads can reprogram/"upgrade" all of their signals to be the same. It should not take more than a decade and a few billion dollars to make the changes.

BTW: What is your source for "Mark # railroading"? Is that your personal categories? I don't see Mark in the NORAC rules and the FRA uses classes of track not "marks".

Torpedo class/type comes to mind. The kind designed to sink ships not the type used back in the day as a warning for trains.

Hi,

There is no need to welcome me back. I can appreciate the tone of this thread and it is worthy of discussion. Typically, Blended Brake, though boisterous, makes an underlying point that is valuable. However, this time there is history and as such, the solutions proposed are part of the problem. Additionally, there is a gaping whole in the solution that hits to the core of what I think is more than a railroad problem.

First, let's go into some of the problems as defined by Blended Brake. Since the crafts of Dispatcher, Engineer and Conductor were specifically addressed by BlendedBrake, we will focus on that area.

The first salvo is poor training. Granted, training (as demonstrated by the Talgo fiasco) is abysmal. The next salvo is poor management that were ineffective in their craft(s) and basically have no where to go but to other management jobs. Sounds good.

Here are some of the thoughts regarding solutions:

For starters;
Establish a non-punative safety culture.
Increase scenario based training.
Refresh ALL operations managers.
Require college degrees as a minimum for upper-mid-level management employees.
Centralize training by establishing a quality assurance department.
Do away with seniority based promotion in favor of merit based.
Open lines of communication for employee feedback.
Work with accredited universities to create railroad specific courses.

I'd like to address some of the problems and how the solutions in some cases led to the problems. Then I will address a major problem (which is a theme that I sprinkle in this thread) and the (possibly unattainable) solution, that of course isn't mentioned and why I think it is problem. That problem and solution boils down to one word: Interest.

How did we get to "poor training?" Well, it is largely because one of the solutions and the employees themselves. Most railroads had decent standards in the not too far past. However, two things occurred. The first was the perfect storm of managers, with college degrees and minimal field experience replacing personnel with tons of field experience that may not have had degrees (although some did degrees). Amtrak has quite a robust college management program. It has been that way for years. The problem with gaining and retaining talent had less to do with who could or couldn't cut it in the craft. It had everything to do with money and seniority...or the lack thereof. When Amtrak managers were well paid, you'd see veteran employees, that had years in their crafts turning to management. They were there to bridge and lead and keep things together. You weren't even considered unless you had years in a craft. Then, Amtrak gutted all incentives. Typically, Amtrak managers were underpaid. As such, attracting talent became problematic. Enter the newbies and employees that had no real interest in preserving the integrity of the craft or passing knowledge. Their interest was avoiding the rigors of the extra list. They came looking for stability and bodies were needed. So, off they went. The management trainees were a bonus. Broke former college students with no real understanding looked at the jobs, thought they were easy and minimized standards since budgets were disseminated from corporate and local training money came from the division pool.

That is because of "centralized training." Training used adhere to regional needs and was operated by divisions involved. There were core requirements but the regions tailored the training to the actual conditions. If an employee transferred to another division, they had to complete the necessary divisional training. This makes sense since sitting Wilmington, playing with an Amfleet can only prepare you so much for tangling with a Talgo train. Playing with a Superliner in Chi means very little when you transfer to the corridor. However, when centralized training occurred, divisions were basically stripped of the budget for training. This sets the divisions up for failure if they allow it because there are only so many choices left. Fund a training program from your division pool (which can be depleted as incidents occur) or

Which brings me to the second part of the perfect storm. It was easy to accomplish since there is minimal interest from the employees and the union (yes, I'm going there) not only allowed it...they ENDORSED it. The training regiment was quite difficult in the past. There were standards such as being able to carry a knuckle for a mile if you were a conductor, being able to remove the emergency windows, changing the hoses on the trains. If you couldn't do, you were not considered for the job. Engineers had to pass a simulator exam and if you failed twice, you were FIRED. Hell, you couldn't even become an engineer if you weren't qualified on a book of rules and had the physical characteristics qualifications on a piece of railroad. No ifs, ands or buts! Dispatchers HAD to have operator experience to be considered. Part of their exam was to be able to name very switch number, signal number and routing scenarios. Over time, the unions started saying things are "too hard." Employees started suing and the public law board started backing them up. In the case of dispatchers and engineers, Amtrak was called out for not being "an equal opportunity employer". Standards were dropped to comply. Even so, people STILL managed to fail...and the union continues to fight for them or lessen standards. Indeed, the conductor craft doesn't even HAVE a training agreement. The engineers, complaining that the simulator training (which is the perfect place for Blended Brake's scenario based training) was unfair, demanded it be minimized. The conductors, (who used to join the engineers in the simulator every two years) stated "it wasn't part of their (nonexistent) training agreement and bowed out. They rejoiced!

Why? One of the main reasons is because there is no interest among the employees.

8thnotch stated that BlendedBrake is on to some thing. I would like to ask them both a question. Tell me about the reaction of your fellow employees when it comes to training. Does the attitude resemble "I have a lot of questions to ask and now is the time to get them answered"....or is it "What time are we finishing? I already know this." Hey, interested employee....don't ask too many questions because we want to get out of here!!"

Even a proposal to make training a little more engaging turned into a union fiasco. A manager who came from another company started making games out of rules class. He had things like Amtrak Jeopardy (which allegedly is still used in management training) and Wheel of Misfortune. What went wrong? The attempt to give little prizes to the victors. The unions fired off letters (paraphrasing since this was quite some time ago) spelling out the terms for compensation and how it must be negotiated and any compensation not negotiated could not be provided without...blah blah blah.

I'm not sure were BlendedBrake and 8thnotch work, but I know a couple divisions tried to take matters in their own hands. Using their divisional pool budgets, one started operating a training train on weekends. Another division started having supplemental rules classes which had scenario based training. The employees complained (since a lot of them were admittedly being summoned on their days off.) The union put up a fuss in their defense, correctly stating an assigned day off is just that...and assigned day off. However, the only time to get the shot for this particular training train was during the weekend, when traffic was down. It covered a lot of unusual situations. They brought in an additional dispatcher to assist. It should have worked out for everyone. Instead, it became a brawl. It became voluntary and people didn't sign up. The union demanded additional personnel to man the training train (and based upon the language in the contract, they were correct in doing so.) Since it was training, it wasn't overtime and employees weren't....interested.

The training potential was there....but the interest wasn't...and without seasoned managers to counter the managers who feel that "this stuff is easy..the engineer just sits there playing with levers as he "drives the train", the conductor is just walking around, punching holes in a piece of paper and the dispatchers are just playing a video game," things like the programs were dropped...much to the delight of the employees. In the case of assistant conductors, now you have an uniformed, disinterested employee, that is turning down training after avoiding yard service for 9 months being sent out to become a conductor, being and being unleashed after passing perfunctory qualifying exams because the previous exams (which were verbal) were ruled to be "discriminatory." Which brings me to the next solution BlendedBrake mentioned:

Doing away with seniority based promotion in favor of merit based.


Sounds good on paper...unfortunately, that practice ended under the equal opportunity complaints and contract violations. Years ago, your divisional personnel had a hand in who got to qualify or got promoted. I'm sure you can imagine what kind of chaos that can lead to. You can have a model employee on your hands but there is juuuuust something about their attitude to irks you. Now, you can control their future. Merit is subjective...unless it is spelled out...which it is. I'm paraphrasing and leaving out a key period, but the long of the short of it is assistant conductors will be promoted to conductor after a certain period of time. It is contractual. It was negotiated. When the company used to hold people out, claiming they weren't ready, they lacked yard experience or whatever reason (let's be realistic, some people probably weren't liked), the union didn't take an objective look at the person in question and say "perhaps you do need more time" like some of the previous, old school union leaders did. They bombarded the company with time claims and stated their members were being denied their seniority and their pay! This didn't even need to go to the public law board as it is indeed a clear cut violation of the contract. So, off everyone went after their minimum period and without an interest in experience or really learning what but why they are taking the actions.

Blendedbraked states that there should be a non punitive safety culture and he is correct. People shouldn't be chastised, harassed or made to feel the pressure of "since you followed that rule that inconvenienced us, just wait until you make a mistake." However, it works both ways. There should be personal accountability as well. I don't know about the rest of you but I don't really don't need a lot of clues or training to know what can or can't save my life...but not everyone is me. If you're truly working safely and you are truly working by the rules on a fairly consistent basis, you'll be remembered as such. However, I do agree with the statement which is why I had hope for the Safe 2 Safer program. It was supposed to be just that...peer observations and recommendations without pressure. It was supposed to raise awareness without management peering down their noses with discipline on their minds.

How seriously did the participants take that program? As such, how did it turn out? Were people interested in the feedback? Were they interested in improvement? What were they interested in BlendedBrake? (you know the answer...there is no need to put it here!) As such, incidents continued to rise, the program scrapped, and now everyone is wondering why people are being charged. Welcome to NS.

As for open lines of communication for feedback, again I don't know where BlendedBrake or 8thnotch works but if there isn't open lines of communications, that is indeed a problem. However, I suspect that the lines aren't being used. There are email systems, cell phone numbers, desks that are staffed 24hours a day that can offer support and guidance. This isn't years ago when cell phones weren't available. You can always leave a message if the person you're trying to reach doesn't pick up. There is an entire intranet that has the email (and often phone numbers) that are available. DN comeout with the office number and cell phone number of your analyst. If you have a question, comment or concern, you have the ability, unlike years ago when if someone wasn't at a desk, you were out of luck. You have a monthly union meeting and your rep is there to solicit feedback. They are your conduit to the company if necessary. If you take matters into your own hands, you can take it right top if you want to. Hell, even PASSENGERS can email the CEO and the executive staff. So can you, if you want to go that direction. Wick Moorman instituted a monthly town hall teleconference and a quarterly business update teleconference. Mr. Anderson has continued the practice. During these calls, there is a 30 to 35 minute live question and answer session. They also take email questions. So, again there are options...if you're INTERESTED in using them.

My bottom line is there is corporate responsibility. There is personal responsibility and that is left out of your list of solutions. The company can do better but so can the employees. Indeed, you are absolutely correct when you stated that if John or Jane Q Public knew what went on behind the scenes at (dare I say most large corporations), they probably say DAMN!!!!!!! or suggest we're lying!

However, I do believe there needs to be a groundswell of internal outrage that comes from personal pride and personal professional pride to help drive the corporate direction.

Now I will address Noel Weaver and other retired railroaders to make my point. Noel, years ago, what did you see when you walked into a typical T&E break room? You count on 4 things:

1) Wafts of cigarette smoke as people ate
2) A card game
and while that was occurring, what was the discussion?
3) rules and the eventual rules fights.

You didn't need college educated managers because you barely needed or had managers. The crews policed themselves. They mentored each other, learned from each other. You didn't need a babysitter to sit behind the desk to say "you didn't sign in." You didn't need a manager to say "you're out of uniform." You didn't need someone to say your book are out of date. The crews handled that themselves. If you were late, the conductor would send you home. There was no appeal!
If you were out of uniform, you were sent home. I remember a conductor that had his engineer hauled away in handcuffs...and not a damn thing happened to him...because he was in charge, knew his job and since he was a freight main that spent many a day on an engine (and in some cases running it since drinking way still going on back then) he knew the engineers job as well!

The 4th was you would see is someone in need of a power nap!

Union reps were cut throat as well! They didn't want to disgrace the crafts so they'd come to you and attempt to straighten you out. They'd warn you to shape up or fail out. Now, you're picking on a person if they arrive out of uniform, 35 minutes late. Managers are taken to task for NOT turning in another person when someone asks why they are being bothered[e.g. Well THAT crew left an hour early, why are you picking on me for leaving 45 minutes early. You're harassing me! So now, everyone is written up...for consistency.) Go into a crew room, and people are talking about anything but railroad. The game, their dates or they're plugged into some electronic device. That's all well and good and relaxation is a good thing. But what happened to the exchange of ideas? The reinforcement of thoughts? The pride and professionalism of knowledge and empowerment? Wait....no one TAUGHT it to me...so its the company's fault. However, there is no interest from most to have these sort of discussions.

You can teach certain things but you can't teach personal pride. Accidents can happen. I don't think anyone means to runs signals, crash or kill people. However, years ago,someone stole an engine. She (reportedly) had mental issues and decided to take the engine for a joy ride around the facility. When the realization set in, the police were summoned. They took the lady off the engine and interviewed her. They asked her why she eventually stopped , she said (paraphrasing since this was a long time ago) "well I saw horizontal lights going against the grain of the track, so I figured it was some sort of signal to stop..so I stopped."

So even an untrained thief with mental issues knew to stop at a stop signal!

But our professionals will continue to blame the company after working on the job for a few years, demanding (and suing) to make sure you're promoted, and then when you drop a car and then sideswipe yourself as you go to the next track (sideswiping yourself...that does take talent), you weren't trained properly. That may indeed be true, but what did you do to further your training? When I was out there, EVERY DAY was training. If I didn't learn something, it was a wasted day. I talked to anyone and everyone! If someone was working on an escalator, I'd ask questions. If I saw a CIH open and a maintainer was present, I'd introduce myself, walk in and ask questions. Out on a wire train? Many questions? Track department? Ticket agent? Whatever! This formed a base of knowledge to expand on.

Which brings me to my potential unattainable solutions. Helping instill personal accountability, professional and pride. I knew people that hated Amtrak. HATED them...yet, they were professional. Noel weaver will tell you, the people looked sharp, acted sharper and demanded the same from those around them. It wasn't for the company, it was for their personal pride. Engineers wore suits to work, ties, blazers. Conductors looked so crisp, you could cut butter on their ties. Dispatchers and operators would come on the head end of the train and look over their territory, attempting to learn nuances and subtleties. Indeed, they would often criticize the methods of the coworkers and take the gained knowledge back to the office.

So, now that you have some of the history, I'd like to know what personal solutions Blended Brake and 8thnotch would like to offer. Blendedbrake took time to write this post on the internet and 8thnotch agreed to some of it but I'd like to know:

1) How many teleconferences you're participated in and what was the response to your questions? Will you participate in the next one, on 2/16?
2) You are obviously quite the learned employee. You've criticized the management regime. Not a problem, but I'm interested in knowing what positions YOU'VE gone for? What can your management style bring to the table? What have YOU done to attempt to make change? Perhaps you can get in there, not learn the dirty secrets and use your pulpit to attempt to educate the masses?
3) If management isn't your thing, perhaps you can make headway in a union position. I'm sure you know what an uphill battle that can be, but don't give up. It's for the greater good, no?
4) When it comes to training, will you demand better training? The next time you're in training class and someone wants to leave or attempt to stifle someone that wants to ask question, will you admonish them? Will you stay later?
5) Will you demand better training? Will you attend union meanings and lobby the union to remove the provision from the contract that basically calls for seniority based promotions?
6) I remember a crew member turning in another crew member for being unsafe and saying the person needed more training. That person was called a rat, traitor and was shunned for quite some time. Would you rise to that persons defense? Would you do the same?
7) How much training and mentoring are you involved in? It needed be formal. When you see see someone struggling, do you go out of your way to help. Would you stay late with them to make sure they are at least improving in your eyes? Is your phone on, all night just in case someone is having trouble? You probably initiate round table discussions with certain people, but what do you make of the people that...seem to have no interest? Do you stress the important of all the teaching moments that have appeared as of late? Along those lines, 8thnotch, if 3 of your former coworkers reappear, will you embrace them with open arms and tell them how they were robbed and cheated or will you go to the union and them and make sure they are well trained? Will you take them and give them tough love or tell them how much they were railroaded?
8) How many letters have you written to the company or union to address the issues raised on this board? I'd like to think that you have and the letters haven't been addressed to your liking, you don't have to give up. Will you push the points you've made on this board...in the proper forum?

Everyone is waiting for someone to do something for them. Take the time to invest in yourself and others by rising up, challenging yourself and demanding excellence (although mistakes can occur) from yourself and others. Good habits get better and bad habits get worse.

As you stated, there is indeed much to do...but it is for EVERYONE...not just management....and that takes interest...not just someone saying "as long as I get paid...."

Is that what you want coming at you?

jesus, just when i thought I had made my last posting on this website...

ThirdRail.....my brother.....that mic just dropped so hard all 4 of my dogs just jumped out of their skins.

On cue, the acting head of the FRA resigned yesterday over ethics concerns, while Congress is holding up a permanent appointment of someone who appears to be a seasoned veteran railroader.

viewtopic.php?f=177&t=166959" onclick="window.open(this.href);return false;

I re-read this thread all,the way through trying to understand where Blended attacked Mr. Weaver, to no avail. The "counter attacks" against BB looked like a diversion at first, but I think more likely a product of past encounters.

On its independent merits, the original statements are well worthy of discussion. I am very appreciative of the constructive comments toward improving safety culture, especially ThirdRail's questions.

I do not work in railroading, but I feel close to it having many, many friends who have worked for the New Haven, Conrail, Amtrak and Metro North. My great grandfather was an engineer on the New Haven, killed by electrocution in the early days. He had been part of the great mutual aid story of railroader's helping the children and widows of accident victims by taking the children into his home. I do work in an industry that has had its share of safety concerns, healthcare. Enough about me.

As many of you know, the beginning of a basic safety culture emerged in 1939 with the horrible safety record of the Boeing B-29 program. You can read more about this in A. Gawande's The Checklist Manifesto. This was adopted by healthcare, as a preventative measure, as a means to prevent surgeons from operating on the wrong site. The idea of time-outs was a result.
The High Reliability Organization (HRO) program grew out of improving safety culture on aircraft carriers. The poor safety record on the Carl Vinson, was the seed for that, IIRC.
This program has been adopted by other industries, such as healthcare, and has resulted in concepts such as 200% Reliability, and Safety Begins with Me. Both of these emphasize personal accountability for safety, with the former representing the idea that one shares responsibility for what came before and what happens after in patient care.
Another technique used is Stop the Line, where clarifying questions are posed and answered. Someone working in environmental services or any other non-clinical or clinical service has the absolute right and duty to stop a process involving anyone up to the CEO, if there is a question of safety.
These are just a small sample of tools available to transform an organization to one of safety champions.

Back to railroading. Any safety program is better than none, but one that is poorly enforced, with infrequent review, and without accountability, is dangerous, not only for cultivating complacency, but also encouraging a false sense of safety knowledge and behavior.
Investment in these types of programs is expensive to initiate, but cheaper in the long haul. It requires a commitment from the employees, the union and management. None of those three entities has been much of a barrier to implementation in healthcare. If an employee thinks that he/she can doze through the programs, they will be held accountable for the knowledge they supposedly learned. Annual, or more frequent, review is mandatory.

I would not care if managers are college graduates, as much as I care that they are trained to effectively and safely manage equipment and the most expensive asset, their employees. Active leadership by unions in safety culture is mandatory, and can drive the process, as I have seen in at least one organization. I like the idea that safety was self-managed in the old days, but we are far past the obvious shortcomings of that method. Too many lawsuits are waiting in the wings, and, more importantly, seemingly higher risk of serious injury and death for us citizens and railroader's.

I'm going to shut up and listen.