BigJim Yet again, there is so much that we don't know!
Yet again, there is so much that we don't know!
Probably the most insightful comment in this thread. My mental model of what happened in this accident has undergone several revisions since first hearing about it and suspect that more revisions will be made to that model as more of the details come out.
- Erik
At some point in the future, if the Nevada Amtrak/Dirt Hauler collision investigation is any indication, the NTSB is likely to release a large document package that will include interview transcripts and other information, this release being in advance of public hearings on the incident. In the Nevada investigation, there were a number of interesting facts within the larger package.
blue streak 1 Want to read the transcripts between conductor and engineer. Maybe the engineer wondered if the conductor was referring to the switch going to the auto yard and not the switch to the siding ?
Want to read the transcripts between conductor and engineer. Maybe the engineer wondered if the conductor was referring to the switch going to the auto yard and not the switch to the siding ?
I've been wondering that too.
Just a little example of how even the best people can sometimes have a momentary lapse. Last week, I was pulled off my regular pool assignment to work the daylight yard engine. (Extra board depleted) The foreman and switchmen were both experienced and ones I would completely trust. Much of the time on the yard engine we sat in the clear while trains came in and out of the yard. We were going down the lead light power to go pull a cut off a track and switch it out, when the dispatcher came on the radio and said he had a short timer lined into the yard. The foreman decided to pull back in the clear and wait. The local manager came on the radio and said to go ahead and grab that cut. So the foreman said let's go back. I pulled up to a trailing point switch lined for us and stopped so he could get off. Instead of waiting for me to pull over the switch, I saw him go to the switch stand, take the hook out of the hasp and throw the switch. Then he gave me a "come ahead" sign. I asked him over the radio, "Are you sure about that?" He immediately realized what he had done and threw the switch back.
So maybe the conductor, handling multiple switches in a short time, may have convinced himself that he had lined the switch normal when he hadn't.
Jeff
This is a classic switch confusion wreck that is quite well known with several references available, including an article about it in Trains magazine. The fireman went ahead to the switch to let his passenger train out of a siding after a meet that was to occur.
The fireman walked up to the switch and unlocked it before the opposing train arrived. From the details that have been published, I believe that the unlocking being witnessed by the engineer, caused the engineer to wonder if the fireman had actually thrown the switch for the siding onto the mainline. So the engineer tooted the horn as if to ask the fireman if he was sure what he was doing.
The fireman took this as a sign of doubt, and then he began to doubt the correctness of the switch. Perhaps to ask the fireman again, the engineer turned his headlight on and off. Time was running out as the opposing passenger train approached, and at the last second, the fireman decided that the switch must be wrong. So he rushed to it with the intent to throw it to the correct position, but it was correct, and he threw it to the wrong position, thus letting the passenger train into the siding to collide head-on with his train standing in the siding for the meet.
https://www.gendisasters.com/new-mexico/2141/springer,-nm-flier-mail-trains-collide,-sep-1956
jeffhergertSo maybe the conductor, handling multiple switches in a short time, may have convinced himself that he had lined the switch normal when he hadn't.
Been there. Even worse if you're trying to think several moves ahead. Never had anything untoward happen, though.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
jeffhergert blue streak 1 Want to read the transcripts between conductor and engineer. Maybe the engineer wondered if the conductor was referring to the switch going to the auto yard and not the switch to the siding ? I've been wondering that too. Just a little example of how even the best people can sometimes have a momentary lapse. Last week, I was pulled off my regular pool assignment to work the daylight yard engine. (Extra board depleted) The foreman and switchmen were both experienced and ones I would completely trust. Much of the time on the yard engine we sat in the clear while trains came in and out of the yard. We were going down the lead light power to go pull a cut off a track and switch it out, when the dispatcher came on the radio and said he had a short timer lined into the yard. The foreman decided to pull back in the clear and wait. The local manager came on the radio and said to go ahead and grab that cut. So the foreman said let's go back. I pulled up to a trailing point switch lined for us and stopped so he could get off. Instead of waiting for me to pull over the switch, I saw him go to the switch stand, take the hook out of the hasp and throw the switch. Then he gave me a "come ahead" sign. I asked him over the radio, "Are you sure about that?" He immediately realized what he had done and threw the switch back. So maybe the conductor, handling multiple switches in a short time, may have convinced himself that he had lined the switch normal when he hadn't. Jeff
23 17 46 11
CSX Rule
401.14 Before departing a location where main track switches have been operated by hand, each crew member must verbally confirm the position of the switches and that they have been locked.
Never too old to have a happy childhood!
BaltACD CSX Rule 401.14 Before departing a location where main track switches have been operated by hand, each crew member must verbally confirm the position of the switches and that they have been locked.
When each crew member verbally confirms the position of the switches, and that they have been locked; does this require that each crew member has observed the switch status, or can crew members confirm this simply by confirming that they have been told this by a crew member who has observed it?
Does each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself?
243129 BaltACD Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture. I was told it was a Cayce Yard crew that had the job of adding power to the 31 auto racks that were already in the siding thus building outbound train Q210 that would later be called to go to Greenwood, SC - Atlanta and then North. None of this is NTSB testimony so it is subject to CYA. . Three times??? Sounds like he is either covering his a$$ or he did not trust his conductor.The latter being the case why did he not contact the dispatcher via radio, cancel the clear call, then walk up and check the switch after the first query? Something is not right with that scenario.
BaltACD Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture. I was told it was a Cayce Yard crew that had the job of adding power to the 31 auto racks that were already in the siding thus building outbound train Q210 that would later be called to go to Greenwood, SC - Atlanta and then North. None of this is NTSB testimony so it is subject to CYA.
Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture.
I was told it was a Cayce Yard crew that had the job of adding power to the 31 auto racks that were already in the siding thus building outbound train Q210 that would later be called to go to Greenwood, SC - Atlanta and then North.
None of this is NTSB testimony so it is subject to CYA.
. Three times??? Sounds like he is either covering his a$$ or he did not trust his conductor.The latter being the case why did he not contact the dispatcher via radio, cancel the clear call, then walk up and check the switch after the first query? Something is not right with that scenario.
Agree....and so we wait on the NTSB.
-Don (Random stuff, mostly about trains - what else? http://blerfblog.blogspot.com/)
EuclidDoes each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself?
Hard to do if the engineer is 150 cars away on the head end.
The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.
zugmann Euclid Does each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself? Hard to do if the engineer is 150 cars away on the head end.
Euclid Does each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself?
Sorry, I misread your post. I thought you said 'visually'.
Not qulaiifed on Chessie rules, but I'll assume:
Conductor is supposed to tell the engineer, or engineer ask the conductor. Probably a rule about double-chekcing in there somewhere. After this last incident I've been doing my best to be pretty specific about asking my conductor that the "(industry) switch is lined and locked normal".
Euclid zugmann Euclid Does each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself? Hard to do if the engineer is 150 cars away on the head end. Yes, I understand that. So then how is Rule 404.14 supposed to be complied with by a crew member that is too far away from the switch to observe which way it is lined? In what way is each member supposed to “confirm the position of the switch and confirm that it has been locked” ? 401.14 Before departing a location where main track switches have been operated by hand, each crew member must verbally confirm the position of the switches and that they have been locked.
zugmann Sorry, I misread your post. I thought you said 'visually'. Not qulaiifed on Chessie rules, but I'll assume: Conductor is supposed to tell the engineer, or engineer ask the conductor. Probably a rule about double-chekcing in there somewhere. After this last incident I've been doing my best to be pretty specific about asking my conductor that the "(industry) switch is lined and locked normal".
Reading our instructions, the engineer by initialing the SPAF (we use entries on the Conductor's Log instead of a specific form) is verifying that a job briefing has been held, either in person or via radio that the switch has been restored normal. The job briefing is required once the switch has been restored normal. There is no way the engineer, in most cases, could visually determine and confirm that the conductor, or whomever was in charge of the switch, actually lined the switch back normal.
When releasing a track warrant in dark territory, it must be stated that all switches used have been restored and locked normal, a job briefing between crewmembers has been held and the conductor's form has been properly initialed.
I think the assumption is that by holding the job briefing, the one handling the switch has indeed lined them all back normal. Of if he hadn't, it makes him realize he hasn't and then he goes and does line the switch. Maybe even the realization that he forgot one if using multiple hand throws.
If you start holding engineers responsible for accepting the trainman's word that switches are lined correctly when they're not, then you're going to have to start holding the dispatchers responsible because they also took the trainman's word that the switch was lined correctly.
edblysard Euclid zugmann Euclid Does each crew member have to verbally confirm that the position of the switch and that it has been locked to each of the other crew members, or just to himself/herself? Hard to do if the engineer is 150 cars away on the head end. Yes, I understand that. So then how is Rule 404.14 supposed to be complied with by a crew member that is too far away from the switch to observe which way it is lined? In what way is each member supposed to “confirm the position of the switch and confirm that it has been locked” ? 401.14 Before departing a location where main track switches have been operated by hand, each crew member must verbally confirm the position of the switches and that they have been locked. “Before departing” and “verbally” ought to be your clues.
Clues for the clueless?
jeffhergert zugmann Sorry, I misread your post. I thought you said 'visually'. Not qulaiifed on Chessie rules, but I'll assume: Conductor is supposed to tell the engineer, or engineer ask the conductor. Probably a rule about double-chekcing in there somewhere. After this last incident I've been doing my best to be pretty specific about asking my conductor that the "(industry) switch is lined and locked normal". Reading our instructions, the engineer by initialing the SPAF (we use entries on the Conductor's Log instead of a specific form) is verifying that a job briefing has been held, either in person or via radio that the switch has been restored normal. The job briefing is required once the switch has been restored normal. There is no way the engineer, in most cases, could visually determine and confirm that the conductor, or whomever was in charge of the switch, actually lined the switch back normal. When releasing a track warrant in dark territory, it must be stated that all switches used have been restored and locked normal, a job briefing between crewmembers has been held and the conductor's form has been properly initialed. I think the assumption is that by holding the job briefing, the one handling the switch has indeed lined them all back normal. Of if he hadn't, it makes him realize he hasn't and then he goes and does line the switch. Maybe even the realization that he forgot one if using multiple hand throws. If you start holding engineers responsible for accepting the trainman's word that switches are lined correctly when they're not, then you're going to have to start holding the dispatchers responsible because they also took the trainman's word that the switch was lined correctly. Jeff
Johnny
In the Cayce collision we are discussing, assuming that the conductor restored the switch for the main line, and engineer was too far away to actually see the switch alignment, how does the engineer “verbally confirm,” according to Rule 401.14?
Deggesty Jeff, what you are saying is that it is a matter of TRUST?
Jeff, what you are saying is that it is a matter of TRUST?
When you get down to it, no matter how many rules you pile on, no matter how much techonolgy you have, it really does come down to trusting people to do what they are supposed to do. On or off the job. I suppose, with the general breakdown of trusting others or institutions, maybe that seems old-fashioned and out of date.
Euclid Well Rule 401.14 spells out the responsibility of the engineer and it sounds equal to the responsibility of the conductor. I assume that the words of the rule are very carefully chosen to say what they mean. In the Cayce collision we are discussing, assuming that the conductor restored the switch for the main line, and engineer was too far away to actually see the switch alignment, how does the engineer “verbally confirm,” according to Rule 401.14?
He has a job briefing with the conductor, either in person when he's back in the cab or via the radio.
jeffhergertWhen you get down to it, no matter how many rules you pile on, no matter how much techonolgy you have, it really does come down to trusting people to do what they are supposed to do. On or off the job. I suppose, with the general breakdown of trusting others or institutions, maybe that seems old-fashioned and out of date. Jeff
We drive though green lights trusting others are going to stop for the red. We trust people aren't going to enter the freeway the wrong way. Isn't 100%, but few things in life are.
Okay, so the conductor confirms on behalf of himself and the engineer. I would not conclude that the conductor telling the engineer which way the switch is lined confirms anything for the engineer. All the engineer can confirm is that the conductor told him the switch was properly lined. Why should the engineer assume any responsiblity for the switch when he does not directly know which way it is lined?
Euclid Okay, so the conductor confirms on behalf of himself and the engineer. I would not conclude that the conductor telling the engineer which way the switch is lined confirms anything for the engineer. All the engineer can confirm is that the conductor told him the switch was properly lined. Why should the engineer assume any responsiblity for the switch when he does not directly know which way it is lined?
Thanks to Chris / CopCarSS for my avatar.
Murphy Siding Euclid Okay, so the conductor confirms on behalf of himself and the engineer. I would not conclude that the conductor telling the engineer which way the switch is lined confirms anything for the engineer. All the engineer can confirm is that the conductor told him the switch was properly lined. Why should the engineer assume any responsiblity for the switch when he does not directly know which way it is lined? Who said he did?
Who said he did?
If you are asking how I know the engineer confirmed, I don’t know that. I am only saying what would be the manner in which the engineer could confirm if he did confirm. I am asking what the rule means by posing examples of how it would apply to the Cayce wreck scenario.
The engineer could not possbily confirm how the switch was lined without seeing it. He could repeat what the conductor said about the switch being properly lined, if that is what is meant by "verbally confirm." If that is what the rule means, I would say that "confirm" should be changed to "acknowledge."
In any case, I have heard comments that the engineer would be blamed along with anyone else on the crew if a switch was left improperly lined. I also assume that would be the idea of having all crew members witness and certify, as appears to be the intent of the SPAF process.
Also, Balt said this earlier:
“With knowledge I have of CSX Discipline - They BOTH have been fired, if the local discipline 'investigation' has been held."
Deggesty jeffhergert zugmann Sorry, I misread your post. I thought you said 'visually'. Not qulaiifed on Chessie rules, but I'll assume: Conductor is supposed to tell the engineer, or engineer ask the conductor. Probably a rule about double-chekcing in there somewhere. After this last incident I've been doing my best to be pretty specific about asking my conductor that the "(industry) switch is lined and locked normal". Reading our instructions, the engineer by initialing the SPAF (we use entries on the Conductor's Log instead of a specific form) is verifying that a job briefing has been held, either in person or via radio that the switch has been restored normal. The job briefing is required once the switch has been restored normal. There is no way the engineer, in most cases, could visually determine and confirm that the conductor, or whomever was in charge of the switch, actually lined the switch back normal. When releasing a track warrant in dark territory, it must be stated that all switches used have been restored and locked normal, a job briefing between crewmembers has been held and the conductor's form has been properly initialed. I think the assumption is that by holding the job briefing, the one handling the switch has indeed lined them all back normal. Of if he hadn't, it makes him realize he hasn't and then he goes and does line the switch. Maybe even the realization that he forgot one if using multiple hand throws. If you start holding engineers responsible for accepting the trainman's word that switches are lined correctly when they're not, then you're going to have to start holding the dispatchers responsible because they also took the trainman's word that the switch was lined correctly. Jeff Jeff, what you are saying is that it is a matter of TRUST?
Euclid Murphy Siding Euclid Okay, so the conductor confirms on behalf of himself and the engineer. I would not conclude that the conductor telling the engineer which way the switch is lined confirms anything for the engineer. All the engineer can confirm is that the conductor told him the switch was properly lined. Why should the engineer assume any responsiblity for the switch when he does not directly know which way it is lined? Who said he did? If you are asking how I know the engineer confirmed, I don’t know that. I am only saying what would be the manner in which the engineer could confirm if he did confirm. I am asking what the rule means by posing examples of how it would apply to the Cayce wreck scenario. The engineer could not possbily confirm how the switch was lined without seeing it. He could repeat what the conductor said about the switch being properly lined, if that is what is meant by "verbally confirm." If that is what the rule means, I would say that "confirm" should be changed to "acknowledge." In any case, I have heard comments that the engineer would be blamed along with anyone else on the crew if a switch was left improperly lined. I also assume that would be the idea of having all crew members witness and certify, as appears to be the intent of the SPAF process. Also, Balt said this earlier: “With knowledge I have of CSX Discipline - They BOTH have been fired, if the local discipline 'investigation' has been held."
Here is the answer I was looking for. When the engineer "confirms," he is not confirming that the switch has been properly lined. He is only confirming that he has been told by someone on the ground that the switch has been properly lined.
“BLET asked that FRA clarify that entry of the engineer's initials is an affirmation that the communication (representation) has been received and not that the engineer can personally vouch for the actions taken on the ground. FRA affirms that the engineer's responsibility is to acknowledge the information provided by the conductor or brakeman, not to act as a guarantor with respect to the actual position in which the switch was left.”
In my earlier comment, I suggested that the word, confirm needs to be changed to acknowledged. And that is exactly what the FRA has done in their language above.
This is from EO 24 found here:
https://www.federalregister.gov/documents/2005/11/25/05-23303/fra-emergency-order-no-24-notice-no-2-emergency-order-no-24-hand-operated-main-track-switches
243129 BaltACD Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture.
BaltACD Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture.
It is my understanding that when the freight job released their block back to the dispatcher, it was immediately given to 91. So how could the freight engineer have called the dispatcher and canceled their previous release of their block back to the dispatcher? Wouldn’t this have required taking the block away from 91?
Euclid 243129 BaltACD Information I have received through back channels - Engineer inquired of the Conductor 3 (Count them THREE) times after the Conductor 'signed off' on his SPAF the switch had been lined for the Main and the EC-1 for the block released back to the Dispatcher - Three times the Conductor reported he had lined the switch for the Main Track. Engineer was in the process of walking to the switch to check it for himself when 91 entered the picture. It is my understanding that when the freight job released their block back to the dispatcher, it was immediately given to 91. So how could the freight engineer have called the dispatcher and canceled their previous release of their block back to the dispatcher? Wouldn’t this have required taking the block away from 91?
Had he not trusted the conductor,yes it would and it would have prevented a tragedy.
EuclidSo how could the freight engineer have called the dispatcher and canceled their previous release of their block back to the dispatcher? Wouldn’t this have required taking the block away from 91?
The important aspect is that the dispatcher, upon receiving a 'cancel release' or whatever, will order 91 to stop as immediately as possible. That is the important thing here. Just how quickly the order will call for may depend on perceived severity; I do not know what the rules actually call for in this specific circumstance.
If the CSX crew anticipates they will need more access to the main (not the case here with the train tied down) they can REQUEST authority from the dispatcher, who would then request it formally from 91.
I suspect if CSX is only checking the switch, the dispatcher will not go through the 'full' TWC procedure, as safety has been achieved with 91 stopped. When CSX has checked and confirmed, 91 would be told to move with the authority they were granted.
It does occur to me that the best thing in this instance -- perhaps in any instance a crew reports a mistaken or premature release of authority -- would be to order the 'next train' to proceed at restricted speed watching what the crew was concerned about. There is no real difference between that and the NTSB recommendation from 2012 that is now being revived as an emergency order.
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