The NTSB does not say that the employees were required to obtain protection to walk on the Amtrak tracks. They do say that per General Safety Rule 10, the operating crews were not prohibited from walking either on or near the Amtrak tracks.
Rule 10 only requires employees to “Stop and look in both directions before making any of the following movements: - Fouling or crossing a track…”
So the CSX employees were fouling a track and they were required to look both ways before fouling. However, if they did that, the rule would allow them to maintain fouling while walking on the track for an indefinite distance. What is missing from Rule 10 in this case is a requirement to look back at specified intervals during the continuous fouling associated with a long walk on the track, in line with it.
So it is true that Rule 10 does not prohibit employees from walking on a track lengthwise with it, however the rule also does not provide any procedure for employees to walk lengthwise on the track, as the CSX employees were doing. Rule 10 does require employees to be alert while on or near tracks, but a fully alert person could still be blindsided by a train if it sneaks up on them from behind and its horn warning is merged with the horn warning of a second train approaching from their front.
Therefore, without a means to seek protection on the Amtrak property; and without a requirement to do so; and with no rule telling them not to walk on the Amtrak track— there was nothing in the rules governing the action of the two employees in walking lengthwise on the Amtrak track.
This leaves the obvious question: If the two conductors were not doing anything wrong, how could the cause of their deaths be their fault as the NTSB determines with their Probable Cause in their report?
Sounds like the NTSB sees the problem is systemic, requiring some structural changes to prevent such avoidable errors, as the current system failed miserably.
The question of whether CSX employees were trespassing by walking on Amtrak tracks is not addressed by the NTSB. That unanswered question resides somewhere within the disjointed and ambiguous NTSB coverage of the topic of the two CSX conductors walking in the Amtrak track instead of CSX property.
That coverage consists of the following points made by the NTSB that are related to CSX employees being on Amtrak property in the following quotes:
“The operating crews were not prohibited from walking either on or near the Amtrak tracks.”
“The NTSB believes that the crew should have been prohibited from walking near the live tracks of the other railroad.”
“However, there are circumstances when the operating employees cannot safely walk away from the other railroad’s tracks. In these situations, when the crew is fouling the other railroad’s adjacent track, they would need protection.9 A current process is readily available to provide this protection.”
“The NTSB believes that this same communication could be used to protect employees that find it necessary to occupy the other railroad’s active tracks. Therefore, to eliminate the hazard of unknown traffic on adjacent tracks of other railroads, the NTSB recommends that CSX and Amtrak prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads.”
“The National Transportation Safety Board determines that the probable cause of the accident was the CSX Transportation train Q137 crew’s decision to walk near an active track without protection.”
There is considerable ambiguity in these NTSB statements. The first statement seems to mean that CSX railroad employees are free to walk on the property of another railroad and do so without protection.
However, in the third statement, the NTSB says that if CSX employees are choose to walk on the property of another railroad; and if that walking fouls the track of the other railroad, it requires protection under an established procedure that is readily available.
So the first statement makes it sound like the CSX employees did not need protection and therefore did nothing wrong. Yet the third statement says that the CSX employees did require protection while fouling the Amtrak line; and therefore, they broke the rule by walking on the Amtrak track within its foul zone.
The fifth statement seems to confirm that the CSX employees broke the rule because it says that the CSX employees’ decision to walk near an active track without protection caused the accident.
HOWEVER: The fourth statement makes it sound like the seeking of protection related to fouling the Amtrak track was not and is not an option, so NTSB recommends that it be make an option. This seems to conflict with their third statement in which they seem to say that seeking status of protection was an option. So which way is it? Well, if it was not an option, does that therefore mean that the CSX employees were not breaking any rule because as their first statement says, “The operating crews were not prohibited from walking either on or near the Amtrak tracks.”?
If they were not prohibited from walking “on” the Amtrak tracks, which they did, then if follows that they did not need protection. If they were not prohibited from walking on the Amtrak tracks without protection, how can their decision to walk on the track without protection, be the probable cause of the accident?
Not according to the NTSB
Probable Cause
The National Transportation Safety Board determines that the probable cause of the accident was the CSX Transportation train Q137 crew’s decision to walk near an active track without protection. Contributing to the accident was their focus on northbound Amtrak train P66 and their failure to realize Amtrak train P175 was approaching them from behind.
Euclid BaltACD charlie hebdo If the Amtrak tracks are owned by Amtrak, how do CSX employees have any more rights to be on Amtrak property than any other (non Amtrak) person, unless they had secured permission in advance for a specified time period? Seems like trespassing otherwise. Google Earth image of the area - Who's tracks are Who's. A diagram and a photo map on page 1 of the NTSB report clearly identifies the tracks. https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf In the image in the quote here, the group of tracks in the upper left corner are CSX, and the group closest to the parking lot are Amtrak tracks.
BaltACD charlie hebdo If the Amtrak tracks are owned by Amtrak, how do CSX employees have any more rights to be on Amtrak property than any other (non Amtrak) person, unless they had secured permission in advance for a specified time period? Seems like trespassing otherwise. Google Earth image of the area - Who's tracks are Who's.
charlie hebdo If the Amtrak tracks are owned by Amtrak, how do CSX employees have any more rights to be on Amtrak property than any other (non Amtrak) person, unless they had secured permission in advance for a specified time period? Seems like trespassing otherwise.
Google Earth image of the area - Who's tracks are Who's.
A diagram and a photo map on page 1 of the NTSB report clearly identifies the tracks. https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf
In the image in the quote here, the group of tracks in the upper left corner are CSX, and the group closest to the parking lot are Amtrak tracks.
That is what zugmann said. So the question you posed remains. Did the CSX workers obtain proper authorization to occupy Amtrak tracks? If they did or did not, there is something wrong with a system that would allow the Amtrak train to come through at speed.
SD70Dude BaltACD The bigger question - why did the Conductor and trainee return to their engines on the side of the train against Amtrak rather than on totally CSX property on the other side of their train. Just a theory, I in no way wish to speak ill of the dead, may they rest in peace. From the NTSB report it appears the freight was a intermodal train (over 9,000' with only 58 cars, had to be a lot of 5-packs). What are CSX's rules regarding crossing over intermodal cars? On CN we are required to maintain 3-point contact at all times when riding or crossing over equipment, and while intermodal cars do have walkways they do not have handrails on the end of the car, so it is impossible to cross over them and maintain 3-point contact. Could the Conductor have been aware of the Trainmaster's prescence on or about their train, and did not want to commit a rule violation in front of him?
BaltACD The bigger question - why did the Conductor and trainee return to their engines on the side of the train against Amtrak rather than on totally CSX property on the other side of their train.
The bigger question - why did the Conductor and trainee return to their engines on the side of the train against Amtrak rather than on totally CSX property on the other side of their train.
Just a theory, I in no way wish to speak ill of the dead, may they rest in peace.
From the NTSB report it appears the freight was a intermodal train (over 9,000' with only 58 cars, had to be a lot of 5-packs).
What are CSX's rules regarding crossing over intermodal cars? On CN we are required to maintain 3-point contact at all times when riding or crossing over equipment, and while intermodal cars do have walkways they do not have handrails on the end of the car, so it is impossible to cross over them and maintain 3-point contact.
Could the Conductor have been aware of the Trainmaster's prescence on or about their train, and did not want to commit a rule violation in front of him?
I believe I read, that at the start of the inspection, the Conductor inspected one side and the Trainee inspected the other. For them to be together, one of them had to have crossed over.
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charlie hebdo BaltACD Google Earth image of the area - Who's tracks are Who's. Whose tracks are whose? The parties in question should know. Clearly none of us (including you) know.
BaltACD Google Earth image of the area - Who's tracks are Who's.
Whose tracks are whose? The parties in question should know. Clearly none of us (including you) know.
I know - that is why I posted the picture. I did not major in English, and what I was taught is about 50+ years in the past - so some things slip through the cracks.
I would guess the bottom two tracks are Amtrak's (cat poles), while the two alongside those are CSX (no cat poles, and an interlocking which the train eas reported to be strung out through).
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The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any
BaltACDGoogle Earth image of the area - Who's tracks are Who's.
charlie hebdoIf the Amtrak tracks are owned by Amtrak, how do CSX employees have any more rights to be on Amtrak property than any other (non Amtrak) person, unless they had secured permission in advance for a specified time period? Seems like trespassing otherwise.
Euclid BaltACD Euclid tree68 Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even. It does seem that way. They had a 'right' to be there - what they didn't have is the proper level of situational awareness for the position they placed themselves in. It was in no way trespassing. I think we need some more details to establish your position on this point (highlighted in red above). On what basis did the two conductores have a "right" to be there, as you say? Were the two conductors working for CSX at the time, and was the Amtrak line on CSX property? If not, who owns the property of the Amtrak line? If the property of the accident site is not owned by CSX, did the two conductors have any authorization to leave CSX property and enter the property of the Amtrak line?
BaltACD Euclid tree68 Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even. It does seem that way. They had a 'right' to be there - what they didn't have is the proper level of situational awareness for the position they placed themselves in. It was in no way trespassing.
Euclid tree68 Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even. It does seem that way.
tree68 Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even.
It does seem that way.
They had a 'right' to be there - what they didn't have is the proper level of situational awareness for the position they placed themselves in. It was in no way trespassing.
I think we need some more details to establish your position on this point (highlighted in red above). On what basis did the two conductores have a "right" to be there, as you say?
Were the two conductors working for CSX at the time, and was the Amtrak line on CSX property? If not, who owns the property of the Amtrak line? If the property of the accident site is not owned by CSX, did the two conductors have any authorization to leave CSX property and enter the property of the Amtrak line?
NTSB recommends that employees be prohibited from fouling the tracks of another railroad without seeking protection status from that railroad. They seem to be tap dancing around the issue of trespass that would occur if employees were to foul the tracks of another railroad without protection status (as was the case in this accident). The grant of protection status would constitute permission from the property owner and thereby eliminate the issue of trespass by default.
If the Amtrak tracks are owned by Amtrak, how do CSX employees have any more rights to be on Amtrak property than any other (non Amtrak) person, unless they had secured permission in advance for a specified time period? Seems like trespassing otherwise.
tree68Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even.
CSX and Amtrak are simply two railroads with adjacent ROW's in the Ivy City area. This is little different from an Interstate highway and a frontage road - next to each other but otherwise unrelated.
As such, the CSX dispatcher may not have had any knowledge of exactly what was happening on the NEC (and vice versa). Balt will know - I'm admittedly making an assumption here.
Regardless - I would opine that the CSX crew was someplace they should not have been - trespassing, even.
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Here there should be no reason to endanger the crew and stop the train along the busy main. If it stops, declare an emergency and slow all trains to restricted or slower. Once again, the dispatchers are not keeping the crews informed of track status in the area. The job is so full of routines that there may be no time to get the big picture. The dispatcher is caught between two hard rocks: inform the crews and follow burdensom procedures. The big picture is lost when all their time is taken up with details.
BaltACDWhy the crewmen did not walk the CSX side of the train is the unanswerable question. Ballast slope has no more bearing in walking CSX tracks that it does walking on the ties of Amtrak tracks.
According to the report, some employees preferred to walk on the ends of the ties rather than on just the ballast, and that is what the two conductors were doing.
Given that information, I would assume that the two conductors had been walking forward to return to their engine, and they were doing so by walking on the ties of the CSX track that was not occupied by their standing train. But when they got to the crossover, their train was strung through the crossover and then occupied the track on which they had been walking on the ties.
So, in order to continue walking on the ends of the ties, they crossed over to walk on the empty track of the nearest Amtrak main line.
BaltACD When walking adjacent to another carriers Main track - and YOU KNOW they are not protecting against you - your head needs to be on swival on virtually every step. This was not done. Why is the question, however, dead men tell no tales - to their benefit or detriment.
When walking adjacent to another carriers Main track - and YOU KNOW they are not protecting against you - your head needs to be on swival on virtually every step. This was not done. Why is the question, however, dead men tell no tales - to their benefit or detriment.
Turn your head while walking and you've taken your eyes of the path. Would be at least a "coaching" event for us.
Jeff
All trains are surprisingly quiet - especially when an employee is in the near proximity to their own trains locomotives. Electric trains, such as Amtrak in this instance are even quieter.
My undersanding of reading the NTSB report is that Q137 had pulled through the crossovers a F Tower about 7 car lengths worth - in this position Q137 is occupying both CSX #1 and #2 tracks and thus protecting itself against all movements on CSX tracks. Why the crewmen did not walk the CSX side of the train is the unanswerable question. Ballast slope has no more bearing in walking CSX tracks that it does walking on the ties of Amtrak tracks.
The NTSB report says: “The operating crews were not prohibited from walking either on or near the Amtrak tracks.”
I find it incredible that employees are allowed to walk on a live track without some type of formal protection. Although I am puzzled as to why the NTSB also said that they determine “that the probable cause of the accident was the CSX Transportation train Q137 crew’s decision to walk near an active track without protection.” Can an accident be caused by doing something that is not against the rules?
In any case, there is a rule that requires: “…be alert for and keep clear of the movement of cars, locomotives, or equipment at any time, in either direction, on any track.”
There are only two senses available to fulfill the requirement to “be alert,” and those senses are vision and hearing. Both are problematic. Hearing can be unreliable because approaching trains can be nearly silent until there is very little time to react. Hearing can also be unreliable because of the sound obscuration caused by multiple sounds coming from different sources, as seems to have been the case with this accident.
Vision can only be reliable to detect approaching trains within the field of vision. When walking in a given direction, there is no field of vision in the opposite direction. So a person cannot possibly be alert to a train approaching from behind if there is no sensory input to indicate this fact. One other element to this hazard is that a person accustomed to being protected by a sense of hearing expects the absence of sound to mean they are safe. So a person can be lulled into the false complacency in that; if they hear no danger, there is no danger. But in fact, that is not always the case.
Relying only on alertness to detect movement on any track in any direction seems practical in a yard where surfaces outside of the foul line of tracks are generally flat and easily walkable; and where a person changes directions often causing their field of vision to sweep all directions and is expecting conflicting movement from any direction as they walk into and out of various foul zones. But for a person walking considerable distance in track direction, in the foul zone of an active mainline, the rule to merely be alert seems quite inadequate.
At Utica, we have no call to foul the CSX tracks, so that's not a problem for us.
On the main, however:
Westbounds have no crossings within earshot of the station, but CSX (and Amtrak) do sound their horns on approaching the station. Eastbound, there's a crossing about a mile and change from the station, and weather permitting, you'll hear that, as well as the blast for the station itself.
Most trains are cleared for 50 MPH through the station, so without that horn blast, yes, one could be surprised.
When listening in on the CSX frequency, there's a DD a couple miles west of the station, so most eastbounds will have tripped that by the time they come into sight of the station. Not so for the westbounds - the DD is out of radio range. Trains in both directions call CPs a couple of miles out, so one has that as well.
I always remember back in the 50's when working on the PRR, looking up the track and not having heard any sound, seeing a headlight come into sight. The passenger train was about a half mile away but with no grade crossings nearby, there was no need for any horn use. I called out HOT RAIL and everyone cleared the track in plenty of time. What impressed me was that there was no audiblle sound of the train. I just hope that I never forget the need to be aware of the rule that you can expect a train on any track at any time and if you don't, it could be fatal. My sympathies to the families of those men who were trying to do their job.
EuclidThe operating crews were NOT prohibited from walking either on or near the Amtrak tracks.
I believe my rulebooks do have a rule that states one is not to foul a track except in the performance of duty.
I don't wish to speak ill of the dead, but for go sakes, don't walk on a active high speed line without proper protection.
Apparently the two conductors were walking on the Amtrak track because it was easier to walk there than walking on the sloped ballast alongside of their train.
The operating crews were NOT prohibited from walking either on or near the Amtrak tracks.
Yet, the NTSB believes that operating crews should have been prohibited from walking either on or near the Amtrak tracks.
Operating crews are required to “…be alert for and keep clear of the movement of cars, locomotives, or equipment at any time, in either direction, on any track.”
So, assuming that the two conductors were not aware of the train approaching them from behind, the essence of the cause is that they failed be alert for, and keep clear of any movement of equipment approaching from behind.
This is where the essence of the unique distraction danger enters the situation. That unique danger is that a person may be prevented from being alert for equipment approaching from behind because they are not looking in that direction and their sense of hearing cannot distinguish the sound of the equipment approaching from behind because it is merged with the sound of equipment approaching from ahead.
The essential kernel of this distraction is that a person walking on the track, being confident that their sense of hearing will make them aware of equipment approaching from behind; may not realize that they have temporarily lost their hearing ability to distinguish the sound of equipment approaching from behind because that sound is merged into the sound of equipment approaching from the front. So, the essence of the danger is, “not knowing what you don’t know.” In other words, a person may believe that they are alert for any equipment approaching from behind, when actually they are not alert to that prospect.
Therefore, a person legally walking on a track cannot be alert to equipment approaching from behind if equipment is approaching from ahead, on any track nearby; unless the person legally walking on the track routinely turns their head and looks back at intervals shorter than the time it would take for a train approaching from behind to reach the person walking on the track. For example, if a person was walking with their back to the direction where the fastest trains would become become visible 20 seconds before reaching the person walking, then the person walking should turn their head and look back at regular intervals less than 20 seconds in duration. This would eliminate the need for a sense of hearing that normally plays a key role in being alert for equipment approaching from behind.
This unique distraction is the same danger that leads to trespassers to being struck from behind because they are not frequently looking back and their sense of hearing needed to distinguish one sound from another is temporarily suspended due to listing to music through ear buds.
I have never seen any railroad rule that details this unique distraction of partially losing situational awareness due to the loss of the ability to distinguish the direction of sound. Do any rules or safety instructions warn employees of this danger? Otherwise, if employees are not aware of this unique distraction danger, they most definitely should be prohibited from walking within the foul line of any active railroad track. And yet, they are not prohibited from doing so. Therefore if employees are not trained to be on guard against this unique distraction danger, they are not adequately trained to perform their duty.
The Conductor involved was the son of one of my supervisors before I retired. I knew him to talk to - but not as a supervisor of his work actions.
The following are my thoughts from my earlier post last year right after the accident. I also posted an example in red that occurred on June 23, 1890.
Two engineers sounded the warning at the same times, so each engineer’s warning obscured the warning of the other.
Euclid Even with a train approaching fast and close, getting into the clear would not have required more than a split second, and would have been intuitive to experienced railroaders. I doubt that air movement created by the train played a role. The fact that they did not get into the clear is evidence that they never saw the train that hit them. One good possible reason for that is that, with both trains blowing horn warnings, the warnings were heard together and not as two individual warnings from two different trains. It is reported that they were walking with their backs to the train that hit them. So they could have seen the other train approaching them, and attributed both train warnings only to the train they saw coming toward them. This type of ironic outcome from horn or whistle warnings causing the opposite of the intended effect has happened before, and I suspect quite often. If so, it actually does seem worthy of being labeled as a “perfect storm” in that it requires two trains approaching simultaneously and each giving warnings that obscure the warning of the other. Here is an historical example of this type of accident: June 1890 23rd, on New York, New Haven & Hartford, at South Lyme, Conn., butting collision between two gravel trains. The engine of one of the trains was pushing the caboose. One laborer was killed and three injured. It appears that the conductors of these trains made meeting points verbally upon their own responsibility, which a coroner’s verdict says was “without the knowledge of the railroad company.” The coroner’s verdict also says that each engineer on approaching the curve where the collision occurred blew a long blast of the whistle, and that very likely these signals were simultaneous, so that neither heard the whistle of the other.
Even with a train approaching fast and close, getting into the clear would not have required more than a split second, and would have been intuitive to experienced railroaders. I doubt that air movement created by the train played a role. The fact that they did not get into the clear is evidence that they never saw the train that hit them.
One good possible reason for that is that, with both trains blowing horn warnings, the warnings were heard together and not as two individual warnings from two different trains.
It is reported that they were walking with their backs to the train that hit them. So they could have seen the other train approaching them, and attributed both train warnings only to the train they saw coming toward them.
This type of ironic outcome from horn or whistle warnings causing the opposite of the intended effect has happened before, and I suspect quite often. If so, it actually does seem worthy of being labeled as a “perfect storm” in that it requires two trains approaching simultaneously and each giving warnings that obscure the warning of the other.
Here is an historical example of this type of accident:
June 1890
23rd, on New York, New Haven & Hartford, at South Lyme, Conn., butting collision between two gravel trains. The engine of one of the trains was pushing the caboose. One laborer was killed and three injured. It appears that the conductors of these trains made meeting points verbally upon their own responsibility, which a coroner’s verdict says was “without the knowledge of the railroad company.” The coroner’s verdict also says that each engineer on approaching the curve where the collision occurred blew a long blast of the whistle, and that very likely these signals were simultaneous, so that neither heard the whistle of the other.
The following is from the final NTSB report just released:
The conductor and conductor trainee may also have visually and audibly detected only a single train approaching them. As they walked southbound, the beam of light from the southbound locomotive, which could have illuminated a sign or object ahead of them, may have competed with or been masked by the light emanating from the northbound locomotive. As a result, they may not have perceived any visual cues from the southbound train. Additionally, given the simultaneous and similar horn and bell sounds from the two trains, the conductors may not have discerned two sources of the sounds and, consequently, concluded that the sounds originated from only one train—the one that they had detected ahead of them. As a result, it appears the conductors were unaware that a second train was approaching them from behind.
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