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Ultimately, this investigation blames the death of the engineer and fireman on the bridge operator.  The investigators state as unequivocal fact that, “the radio conversation caused the engineer to disregard the visual wayside indications.”  And, yet their only evidence of this is that it could have occurred.   <o:p></o:p> So, what the investigators have concluded is that because the verbal message from the operator came first, it was the act that set the events of the accident into motion.  The investigation nearly forgives the engineer because he merely acted on false information from the operator.   <o:p></o:p> And yet, the investigation found the engineer to have a blood alcohol level that is very near the point where it is illegal to drive a car.  And this was a B.A.C. level was tested after the engineer’s body was removed from the wreckage of the cab, which probably took significant time.  That time may have diminished the B.A.C. measurement from where it was at the time the engineer failed to respond to wayside signals.  Moreover, the report asserts that both the engineer and fireman consumed alcohol while on duty the day of the accident.      <o:p></o:p> It should be noted that the operator’s behavior in this matter, while a rules violation, did not arise from carelessness, lack of attention, indifference, impairment, dishonesty, recklessness, ill will, laziness, or malice, as is often the case with a rules violation.  The company gave the employees radios and told them to use them to improve transportation.  In his own mind, the operator was going beyond the call of duty to help the engineer of the train get it over the road.  He was using the radio to “improve transportation.”   <o:p></o:p> But the operator did make a mistake by breaking a rule that forbade the use of the radio to control train movements.  And he seemed to have committed a greater error by not informing the crew that he had changed his mind, and was not going to have the route lined up for them.   <o:p></o:p> That is perhaps the hardest action to understand.  But was it really an error?  He knew that the signals were the overriding authority, so logically; there would be no need to tell the crew that the signals would not be clear.  He used the radio to improve transportation.  Using the radio to tell the crew that the route would not be clear would do nothing to improve transportation.  It is fairly easy to see that reasoning in the mind of a logical man.   <o:p></o:p> Maybe he failed to inform the crew that he had rescinded his advice about the route being clear simply because he forgot.  But that could not have been a rules violation since the creation of the subject of the retraction was against the rules in the first place.  <o:p></o:p> In any case, whatever the reasons for the operator’s actions were, the actions per se do not explain the cause of this wreck, and they may not have been even connected to the cause.  It may be true, as some have suggested, that the NTSB is free to speculate and use the experience of their best judgment in accident investigations.  But to state as fact that the actions of one man directly caused the death of two other men without any proof strikes me as a supreme injustice.
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