ALL FOR THE WANT OF A TRANSDUCER.

In the same way that the lack of a horseshoe nail led to the loss of the kingdom, the lack of a component might have contributed to the notorious East Palestine wreck.

The 164th car of a Norfolk Southern train triggered a critical hot box detector alert before a May wreck in Pennsylvania, but the train continued on its journey for 15.34 miles before derailing because neither the crew nor the railroad’s network operations center received the warning that would have required the train to stop immediately, the National Transportation Safety Board said in a preliminary report released today.

Signal maintainers working in the area two days before the derailment detached and reattached track-mounted hot box detector components, the NTSB said, but the transducers were attached incorrectly and prompted the detector to report reversed train travel directions.

Data logs don’t show that Norfolk Southern’s advanced train control desk in Atlanta received an alert from the detector, the NTSB said. The advanced train control desk requires an accurate report of train travel direction to interpret hot box detector data. “Under NTSB investigators’ direction, signal maintainers corrected the transducers’ positions. In subsequent tests, NS technicians at the ATC desk in Atlanta confirmed that they had received usable [hot box detector] data,” the preliminary report said.

A concatenation of small errors leads to a train wreck.

“Post-accident examinations did not identify conditions that would have prevented the HBD from transmitting an alarm message,” the NTSB added. “However, NTSB investigators reviewed the inward-facing image recorder and audio data from the head-end locomotive of train 14M and did not find evidence of an audible alarm being broadcast over the locomotive radio.”

Preliminary results of an examination of the locomotive’s radio showed that it was working, but investigators found a loose coaxial connection between the antenna and radio. NS has sent the radio to its shop in Roanoke, Va., for further analysis.

I suspect that the recriminations will continue; I also fear that the old paradigm of outside consultants will lead to no meaningful changes. "[L]ast week the railroad announced both the appointment of an outside consultant to lead an independent review of safety practices and a commitment to partner with labor unions to improve safety."