mlrr wrote:....hence the explanation for sabotage and why it is unfair to blame part of the accident on failure of the infrastructure which is what is being suggested.
When the word system was used I think the reference was not to the physical plant but to overall managerial control over operations. I don't think anyone questions the way signals, switches and equipment worked. As for the alerter having been tampered with, I think the Safety Board was fairly well convinced that Gates didn't tape it shut, that it was already taped shut.
That they found other locomotives had been tampered with as well. That they questioned why Conrail management was either unaware of this or failed to take steps to stop it.
The system issue the NTSB raised in this incident and others was that there was a lot of questionable conduct involved yet the managers seemed unwilling to confront it. Gates said many of the Conrail crews got high or drank alcohol when they were working. That if you wouldn't get high you were shunned. I believe the NTSB found it hard to believe that no one in Conrail management was aware of this yet there was no corrective actions being taken. In fact it seemed management was ignoring it.
The NTSB had also raised this issue in a number of other incidents where drinking was involved. Where it seemed obvious a crew member had been drunk when they reported for duty yet no supervisor was willing to tell them, "You're not getting on that train, buster. Go home and sleep it off."
My feeling is that society had changed a good deal during the 1970s and '80s and the railroads, like a lot of industries, were getting a different kind of employee. That management had a tough time knowing how to deal with this new employee. That supervisors were maybe unwilling to take someone out of service because they were afraid upper management wouldn't back them up.