CSX Fatalities Probable Cause, Ivy City, DC

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CSX Fatalities Probable Cause, Ivy City, DC
Posted by Euclid on Wednesday, June 05, 2019 7:09 PM

Some questions are raised by the CSX accident at Ivy City, D.C. in which a conductor and student conductor were struck and killed by an Amtrak train. 

In other discussion of this topic, some have expressed certainty that death of the two conductors was due to their negligence in deciding to walk on an Amtrak track as they returned to their locomotive.  They were struck and killed by an Amtrak train approaching them from behind at the same moment that another Amtrak train was approaching on the other Amtrak track from ahead of them.  So an obvious conclusion is that they were not paying enough attention, were not expecting trains on any track, any time, etc.  And yet once a person decides a track is clear to cross, they have correctly ceased expecting a train.  So the rule is somewhat of a platitude.   

It is clear that had they not been fouling the Amtrak track, they would not have been struck. Yet their job on CSX required them to inspect a CSX freight train which meant walking along much of that train.  I am not sure of which side it was necessary to walk in this particular case, but the point is that it could have been either or both sides.  So my question goes to the larger premise of how it can be considered safe to inspect a train in such close proximity to the Amtrak line even if the inspecting personnel are not actually fouling Amtrak.  Or more precisely, how do you work in such close proximity to the foul zone of a track without inadvertently entering it?

In their accident report, the NTSB says the following: 

  1. There is not any prohibition against employees walking on a live track.

  2. There is not any system by which CSX could request that Amtrak provide protection for CSX employees working in dangerous proximity to Amtrak track.

  3. NTSB wishes there was such a system and recommends that it be set up by both companies.

  4. The cause of the accident was the decision of the two conductors to walk in the fouling zone of the Amtrak track. 

 

The CSX train was on one CSX main with the hind end cars, and the other main with the head end cars.  It was also occupying a crossover between the two mains.  Focusing on the head end portion of the CSX train since that portion was along the track on which the conductors were struck: 

On one side of the standing CSX train (head end), there was a CSX mainline track; and on the other side was an Amtrak mainline track. If there were a train on the Amtrak track, its side would be about 5 feet from the side of the CSX train. So that is a 5-foot wide space for a person to stand in.  This is the space that would be safe for a conductor to be in while inspecting the train. 

Inside of the 5-foot space, one side is defined by the presence of the stopped train being inspected.  The other side is defined by the start of the fouling zone for the Amtrak track.  At the threshold of this fouling zone, a person would want to allow a little more space because it would be unsafe to use up all of the space right up to the point where you contact a moving train.  So how much of the 5-foot zone of clearance can you use when inspecting a train?  Specifically, how close can a person safely be from the fouling boundary of a fast passenger train?  Bear in mind that air movement and spatial disorientation can also be induced by a fast train at close proximity. 

It is my understanding that Amtrak trains on this stretch of track are allowed to travel at speeds up to 125 mph.  So in terms of safe railroad practice, how close can a worker be to a 125 mph passenger train?  What do the rules say about this?  Where is the line drawn?  If you clear the train by one inch, it is not going to hit you.  But how can a person be expected to work safely even within a couple feet of contacting a 125 mph passenger train?  At the site where the conductors were killed, such a train could not have been seen until it was only about 8 seconds away from them.   

In my opinion, I would consider anywhere in that 5-foot clearance zone to be unsafe unless there was formal train protection provided to assure that no trains would pass on the empty Amtrak track.  

Yet, because CSX and Amtrak are two different companies, there is no system by which CSX can arrange protection from Amtrak trains.  The two conductors killed in this accident did not have the option of protection.  Whether their job required them to be in the fatal location in this specific case, I don’t know.  But it certainly could have required that, and no doubt would require that in the future, and has probably required it in the past.  And yet CSX has no means of protecting employees from this extremely dangerous need to be working in or near the fatal foul zone.  I find it incredibly odd that CSX, like most railroads, has an ultra-high sensitivity to safety hazards and safe practices to address them.  But then they have no concern about the danger of sending train crewmen into the death trap of working on the ground, in confined spaces, with 125 mph trains passing within a couple feet of them, and only a few seconds of warning. 

I also find it odd that the NTSB would find the probable cause of this accident to be the two conductors deciding to walk on the Amtrak track, while telling us that the employees were entirely permitted to walk there. 

https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf

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Posted by tree68 on Wednesday, June 05, 2019 7:52 PM

Euclid
I also find it odd that the NTSB would find the probable cause of this accident to be the two conductors deciding to walk on the Amtrak track, while telling us that the employees were entirely permitted to walk there. 

Just because you can, doesn't mean  you should...

A cardinal rule of being near railroad tracks is always expect a train.

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Posted by BaltACD on Wednesday, June 05, 2019 9:13 PM

The only way we can 'learn' more about this incident is from technology that has not been invented 'yet' - downloading the last thoughts of the deceased so they can be read and 'understood' by those that continue to live.

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Posted by mudchicken on Wednesday, June 05, 2019 10:51 PM

BaltACD

The only way we can 'learn' more about this incident is from technology that has not been invented 'yet' - downloading the last thoughts of the deceased so they can be read and 'understood' by those that continue to live.

 

Live track and you are "working"* less than 19 feet from the center of that live, controlled track without protection ....YOU SHOULDN'T BE THERE

Train crews are NOT exempt from the FRA on-track safety rules. (all inclusive and obviously nobody was acting as a lookout here - situational awareness failure, they fouled a track they did not control or have access to control - technically they were unqualified trespassers on another railroad and obviously they also fouled the other railroad's track to boot. Not Good. They were "working" where they should not have been.) The excuse that they were over where the walking was easier doesn't fly.

Here in Denver, RTD (light rail) is having issues with UP and BNSF employees fouling their main track causing several near miss incidents.

Truly sad chain of events compounded by a 214 OTS violation.

(*) Out west on UP or BNSF and you are working on track machinery or on foot less than 24 feet (company rule exceeds FRA) from an adjoining live controlled track, you must be off the machinery and in the clear when another train or work equipment passes by on that controlled track. All work stops until the passing train or equipment is by you and you can see it's clear. (Speed/ Vision Distance rule applies) 

Mudchicken Nothing is worth taking the risk of losing a life over. Come home tonight in the same condition that you left home this morning in. Safety begins with ME.... cinscocom-west
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Posted by Euclid on Thursday, June 06, 2019 10:01 PM

BaltACD

The only way we can 'learn' more about this incident is from technology that has not been invented 'yet' - downloading the last thoughts of the deceased so they can be read and 'understood' by those that continue to live.

 

Knowing the last thoughts of the deceased is not necessary to preventing this from happening again.  There is plenty that can be learned from this accident.  And it should not have required this accident to learn what needed to be known.  If any thought process needs to be examined, it is that of the NTSB.

In referring to whether or not the two conductors were prohibited from walking on the Amtrak track in the manner they did; I am stating the thought process of the NTSB as they detail in their accident report.  Here is their thought process as extracted from their report. The following four statements are in sequential order and context, but broken out to make them clearer: 

“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.”

“A current process is readily available to provide this protection. For example, a train dispatcher will communicate with another train dispatcher from a different railroad if a derailed train has obstructed an adjacent railroad’s track.”

 

Regarding whether or not the two conductors were prohibited from walking on the Amtrak track, Essentially, I interpret the above four NTSB statements as follows:

  1. Were not prohibited.

  2. Should have been prohibited.

  3. Were prohibited.

  4. Were not prohibited.

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Posted by BaltACD on Thursday, June 06, 2019 10:32 PM

Knowing the last thoughts of the deceased is the only way to intellegently formulate rules and instruction to prevent future individuals from being sucked into the same series of 'trap events' that caused the demise of the original individuals.

Today we can only surmise, withoug knowing, what they were actually thinking - whether their brains had even acknowledged the presence of Amtrak 175, let alone whether they had started to take avoiding actions.  The human mind responds to many inputs - both internal and external, to be effective in prevention we need to know what inputs had control of the brain(s) in the final seconds and formulate strategys so that 'proper' self preservation thoughts take control of the brain at the earlies possible moment.

Writing arbitrary rules is a sure way to have them violated and generally with catastrophic consequences.

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Posted by Euclid on Saturday, June 08, 2019 9:32 PM

BaltACD

Knowing the last thoughts of the deceased is the only way to intellegently formulate rules and instruction to prevent future individuals from being sucked into the same series of 'trap events' that caused the demise of the original individuals.

Today we can only surmise, withoug knowing, what they were actually thinking - whether their brains had even acknowledged the presence of Amtrak 175, let alone whether they had started to take avoiding actions.  The human mind responds to many inputs - both internal and external, to be effective in prevention we need to know what inputs had control of the brain(s) in the final seconds and formulate strategys so that 'proper' self preservation thoughts take control of the brain at the earlies possible moment.

Writing arbitrary rules is a sure way to have them violated and generally with catastrophic consequences.

 

I assume their final thoughts were of great shock, surprise, and regret.  I also assume that they were not aware of #175 coming up from behind them until either after the train struck them or just a second or two before it struck them.  And I assume that they would not have been killed or injured had it not been for the unusual synchronicity of two Amtrak trains converging on them at precisely the same moment.  If #66 was not approaching, they would have most assuredly heard #175 coming up behind them. 

What we can learn is to understand the highly unique danger of this unusual type of accident.  What protects people from it is far less dependent on how careful they are, but mainly dependent on the rarity of the necessary coincidence of two trains converging on a person simultaneously. 

The essence of the Rule 10, which applies to this case, is that an employee must be alert for approaching trains at any time, in either direction, on any track.

What is lacking is that the employee must also be alert to a loss of alertness for trains.  That is the killer. Being alert to approaching trains requires the sense of sight or hearing.  Hearing works full time, while sight varies according to its direction.  Sight cannot be in every direction at the same time.  So, a fully alert person needs both sight and hearing.  Hearing fills in the gaps in sight as sight confines itself to only one direction at a time.

When a train does approach, it tends to fulfill the expectation of an alert person expecting a train.  It sort of closes that loop, so to speak.  At that moment, a person tends to lower their wariness because they have been expecting train, and now they perceive it to be arriving.  Therefore, with lowered wariness, it becomes easier of overlook the existence of a second train approaching.    

Then also, at that critical moment of reduced wariness, the person loses the ability of their hearing to distinguish source and direction of sound because sounds of both trains combine and are perceived as the sound of just one train. 

To further compound the problem, the approach of the one train that the person sees draws the person’s attention to it, thus making them less likely to look in other directions for other trains.  They were expecting a train and that one train has arrived.  It is unusual for a second train to arrive at exactly the same time, and they do not expect that even though the rule requires that.  The vision of their eyesight binds their attention to that approaching train they see. 

This is the death trap that is sprung every time two trains converge on a person.  This sudden loss of the ability for hearing to distinguish sound direction and source happens without notice to even the most otherwise alert person.  So it leaves a person defenseless without realizing it.  The only thing that saves people is the rarity of the two-train coincidence.  In that circumstance, the “be alert” rule is almost irrelevant.       

Therefore, part of the solution to the problem is to rewrite rules to keep people off of live track with protection assuring that no train will approach them.

But the other part is that we can better understand this odd event of distraction that can occur as a sort of perfect storm of two trains converging on a person who thinks he/she is perceiving just one train.

The mechanics of this unique distraction hazard are very clear and predictable.  It does not require deep analysis of a person’s thought process in order to develop some type of self-preservation defense.    

All that is needed is a training exercise that will subject a person to this direct experience of losing the ability to distinguish between the two sounds of two trains.  You can tell people about it all day long, but they will not likely absorb the deep meaning.  They will refuse to mentally place themselves into the situation you describe to them.  A simple test needs to be set up to show people by direct experience how sinister this odd danger really is.  Once they experience that, they will always catch themselves when they are relying on the sense of hearing at times when it may suddenly become incapable of protecting them.  There is no need for writing a new rule. 

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Posted by BaltACD on Saturday, June 08, 2019 10:45 PM

Euclid
All that is needed is a training exercise that will subject a person to this direct experience of losing the ability to distinguish between the two sounds of two trains.  You can tell people about it all day long, but they will not likely absorb the deep meaning.  They will refuse to mentally place themselves into the situation you describe to them.  A simple test needs to be set up to show people by direct experience how sinister this odd danger really is.  Once they experience that, they will always catch themselves when they are relying on the sense of hearing at times when it may suddenly become incapable of protecting them.  There is no need for writing a new rule.

Until you realize that ALL trains can be on you without your hearing them.

In the last 11 years - 4 employees of CSX's Baltimore Division have been killed when being struck by trains that overtook them from behind. 

In Philadelphia a Conductor was ridng on the 4th unit of the engine consist when the train was stopped at its crew change point - a following train on an adjacent track struck him in the center ditch between the tracks.

At Doswell, VA a local freight conductor was walking the brake release on his train, North to South, which was on #4 track (which was used as a siding at this location) when he was struck by a passing Southbound operating on the adjacent #3 track - The conductor had been informed that his train, in addition to its brake test, was being held for the Southbound.

And we have the two employees at QN Tower.

In all three of these incidents the employees were 'near' the locomotives of their own train which were idling and thus making a noise , over which it would be difficult to hear any other trains - diesel or electric; and most difficult to hear a electric train.

All these employees knew they were walking along Main Tracks and should expect movements on those tracks in any direction at any time.  Each of these employees, except the trainee, had multiple years of real world, real time railroad experience - why they did what they did, we will never know.

I posted the following video from the late 40's in the Factual Video's thread yesterday - being hit by movements has been a issue with railroad operation since the formation of railroads.

https://www.youtube.com/watch?v=BqpayZ2JqlU

 

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Posted by SD70Dude on Saturday, June 08, 2019 11:02 PM

RE:  Disorientation,

A few times at work I have been unlucky enough to find myself between two yard tracks that are both occupied by moving trains (usually one of them is my own train).  It is surprising how small the space between tracks is and how little room for error there would be when walking with your head on a swivel.

15 mph seems like 100 when the cars are inches away.

When caught in that situation I will kneel, to avoid becoming disoriented and unbalanced and accidentally stumbling and falling between the moving cars.

The noise problem Balt mentions is very real, when next to a running locomotive one cannot hear much of anything else.  Even your portable radio, with the speaker held next to your ear, is very difficult to hear.  But the fact is that trains are big, noisy machines, and that is not going to change anytime soon. 

A few years ago in Saskatoon, SK a 30-year conductor was struck and killed by a train on an adjacent main track, while he walked back to uncouple the head-end portion of his train.  This was in daylight, with the oncoming train displaying blazing headlights and desperately whistling to try and warn him, to no avail.  We still don't know why he did not move, even though the outside-facing camera from the oncoming train caught everything. 

Greetings from Alberta

-an Articulate Malcontent

NDG
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Posted by NDG on Sunday, June 09, 2019 7:52 AM

 

Forty Years Ago.
 
One of the fears I always worked with was being party to an " Incident " where an Employee was struck by a train, either his own, or another in the line of duty.
 
It never happened.
 
However, I was On Duty when a Trainman reached in to open the knuckle and align the drawbar as the rest of his train was backing down to make the joint.
 
He did not move fast enough, the cars were too close, and his hand got coupled.
 
I was fifty miles away and missed one half of the conversation, but knew something had happened by the surge of panicked Radio Traffic.
 
The mill's First Aid man ran to assist.
 
A Helicopter was sent.
 
We saw it come in.
 
He lost his hand just above the wrist.
 
He was 21.
 
 
Points, Hard Hat, Broom.
 
 
Thank You.
 

 

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Posted by Convicted One on Sunday, June 09, 2019 12:28 PM

Several good points advanced by all. 

I'd just like to add that there is a tendency among us all to promote ourselves to "expert" the longer we work at any given task. Doesn't matter if you're a T&E crew, a boiler mechanic, or an electrician. You get into a routine that you are comfortable with, before long that routine becomes your definitive standard for the "right way things are to be done", and you get to a point where you no longer see any validity in questioning yourself. 

That sense of self-assuredness can leave you vulnerable. Human nature, to a large extent.

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Posted by tree68 on Sunday, June 09, 2019 3:03 PM

Convicted One
That sense of self-assuredness can leave you vulnerable. Human nature, to a large extent.

That loss of situational awareness has cost its share of firefighters, who, unaware that the entire building is actually alight want to push on inside - "we got this."

A fellow has created a website (and does lectures) entitled "Situational Awareness Matters."  It's something we all need to be reminded of from time to time.

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Posted by Convicted One on Sunday, June 09, 2019 3:24 PM

It's truly amazing how quietly a "coasting" train can move along. I've been surprised a number of times standing trackside while facing one direction, only to have a train come by from behind me.  First awareness being the blur as in comes into my field of vision. 

So, I can kinda understand how a person who spends years walking along the side of trains for a living, could one day fall victim to their own complacency. 

Few years ago NS was re-routing some east bound trains off the Waterlevel route and onto  former NKP and PRR track to get the trains from Chicago into Ohio. They were operating a temporary fuel pad with a tanker truck near a  fairly active junction with the former Wabash.

During the time that the fuel pad was in operation, passing trains on the adjoining tracks operated their bell function  well before and well after the actual passing.

This seems like good practice to me. Making me wonder if something like this might have helped the conductors in the OPs  story. 

Of course in my example, all operating personnel were Norfolk Southern, so a coordinated solution was easy.

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Posted by BaltACD on Sunday, June 09, 2019 4:24 PM

Things that has made trains 'quieter' than they have ever been - 

1. Welded Rail - no more clinking rail joints.
2. WILD Detectors - (Wheel Impact Load Detectors) the thumping of flat spots are being eliminated.
3. Quiet Zones - no more routine sounding the horn for road crossing.

When the breeze is blowing in the 'wrong' direction - a train can be there and you never heard it coming  

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Posted by Euclid on Sunday, June 09, 2019 5:53 PM

The trains in this Ivy City accident were not quiet.  They were both blowing urgent horn warnings that could probably have been heard a mile away. 

There is a category of accidents in which employees on the ground are struck by a train or rail equipment.  I believe that at least 99% of them have heard and memorized the rule about expecting trains on any track, any time, etc., and they believe they are abiding by that rule all the time.  It is a rule that requires no specific action or work other than to “expect.”  It is also a rule that goes without saying.   It is a rule that just can’t seem to know what real advice to give.   

In the category of accidents in which employees on the ground are struck by trains, a more specific variation of this category is a subset in which employees have suddenly lost the protection of their hearing due to the sounds of two trains merging to the extent that they sound like one train.  The mistake made by these victims is that they are not using their eyes enough when they encounter this blended sound of multiple trains.  Yet, they are always “expecting trains on any track, at any time…”  But here is the essence of the danger:  People falling victim to it do not realize they are vulnerable.  They don’t know what they don’t know.  They don’t realize that they have suddenly, and by very rare circumstance, lost a critical part of their protection.

Other subsets of this category of accident have slightly different causes such as being distracted by one’s own thoughts to the extent that they completely lose situational awareness.  Others are caused by sounds that simply drown out the sound of an approaching train.  These could be the sounds of your own engine, the radio, or the wind. 

There is another subset which involves the approach of trains that are so quiet that they are unlikely to be heard in time to get out of the way.  Trains in snow fall into this category.

But for the one subset I am focusing on, the accident at Ivy City, DC is a perfect textbook example.  Two nearly identical, opposing trains were approaching at the same speed, on parallel tracks.  They met precisely where the two conductors were fouling one of the two tracks.  Both trains blew the horn long and urgently.  Both shook the ground under the two employees before the trains arrived at their location.  Both were in plain sight.  The two conductors undoubtedly head and felt both trains, but they only saw one of them; and they believed what they heard and felt was the one train they saw.    

So how do you protect people from this unlikely, but possible death trap?  The only way is to teach them ahead of time about it.  They must be made to actually experience the terror of this amazing deception.  Once they have experienced that, they will never forget it, and that will leave them always watching out for it. 

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Posted by BaltACD on Sunday, June 09, 2019 7:10 PM

Euclid
The trains in this Ivy City accident were not quiet.  They were both blowing urgent horn warnings that could probably have been heard a mile away. 

Unless you have been in the Ivy City area, you have no idea just how noisy the area is.  The highway New York Avenue runs parallell to the railraods on the East side of the right of way (if you consider the railroads running North-South) with all the noise that a urban 4+ lane highway generates.  On the West side is Amtrak's Ivy City servicing facility for both cars and locomotives.  Even if there were no operating trains in the area - the area is still noisy - how noisy on a sound meter, I have no idea.  DC Metro operates in the near area and generates its own noise factor to add to the cacaphony of all the other noises.

The ambient noise factor does not excuse the appearant lack of 'personal attention' to the CSX employees.  They were within a car or two of their trains locomotives, walking South they had full view of Amtrak 66 headed North - and according to testimony of Amtrak 175's Engineer, they never looked back to see 175 approaching.

I dare say the Conductor had more 'training' on his job functions than any of us have had. https://dms.ntsb.gov/public/62000-62499/62103/622765.pdf  Unfortunately, the one real test of all this training - he failed and paid the ultimate price for his failure.

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Posted by Convicted One on Sunday, June 09, 2019 7:26 PM

Euclid
  Once they have experienced that, they will never forget it, and that will leave them always watching out for it

I can agree with most of your post, except that part.  The  potential for distraction is too big a variable to have 100% confidence that it will not be a factor.

Problems at home, problems with the boss, problems with creditors, etc...all are the types of things that a person might dwell upon spontaneously, at just the wrong moment. Even the most disciplined of minds ocassionally derail.

It would be nice to think that 100% of all accidents are preventable,...but due to the human factor I think that is a bit of a dream.

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Posted by Euclid on Sunday, June 09, 2019 9:36 PM

BaltACD
 
Euclid
The trains in this Ivy City accident were not quiet.  They were both blowing urgent horn warnings that could probably have been heard a mile away. 

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Posted by mudchicken on Monday, June 10, 2019 3:42 PM

What part of "you were trespassing on the other guy's railroad" isn't registering here? They had no business being THERE. You were encroaching on ground controlled by somebody else that did not know you were THERE. If they were qualified on that territory, they should have known not to be THERE. (No idea if the conductor-trainee had any time on that territory in some other job classification.) The whole d*mned thing is troubling - situational awareness (again).

 

PS - Don't try to erect a fence in the foul zone. If you do, you get the mess & dillema that METRA is stuck with.

Mudchicken Nothing is worth taking the risk of losing a life over. Come home tonight in the same condition that you left home this morning in. Safety begins with ME.... cinscocom-west
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Posted by Euclid on Monday, June 10, 2019 4:48 PM

mudchicken

What part of "you were trespassing on the other guy's railroad" isn't registering here? They had no business being THERE. You were encroaching on ground controlled by somebody else that did not know you were THERE. If they were qualified on that territory, they should have known not to be THERE. (No idea if the conductor-trainee had any time on that territory in some other job classification.) The whole d*mned thing is troubling - situational awareness (again).

 

PS - Don't try to erect a fence in the foul zone. If you do, you get the mess & dillema that METRA is stuck with.

 

 

It registers with me, but apparently not with the NTSB.  As I mentioned at the start of this thread, they seemed to be dancing around variations on the theme of whether the two employees has a right to be where they were.  They never made it clear.  They said nothing about trespassing on Amtrak property.  I see the property line marked in their diagram midway between the tracks of each company.  But they say the diagram is not to scale, and they are right about that.  The diagram makes it look like there is maybe at least 20 ft. between the nearest mains of the two companies.   

But, in one of the photos related to the NTSB investigation, the adjacent mains of CSX and Amtrak appear no further apart than the two mains of each company.  It looks like the property line is about 2.5 ft. from the side of a CSX train.  It looks like a four-track railroad.  How can they have the property line so closed to their trains?  I was wondering if they might have some kind of agreement to allow joint use of the property there. 

 

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Posted by mudchicken on Tuesday, June 11, 2019 12:51 AM

Common occurence under the old (pre-1996, pre- 19 ft rule for OTS) design standard. You can find it in just about any major terminal with more than two railroads.

Mudchicken Nothing is worth taking the risk of losing a life over. Come home tonight in the same condition that you left home this morning in. Safety begins with ME.... cinscocom-west
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Posted by Convicted One on Tuesday, June 11, 2019 6:51 PM

Euclid
It registers with me, but apparently not with the NTSB.

The NTSB's recommendation per the report at your link address appears to me to adequately address the situation "going forward"...unfortunately it's a hard lesson learned...but some are just that.

Question, I guess in order to comply with the NTSB's recommendation, the communication between the two railroads would take place at the "dispatcher" level...correct?

The CSX dispatcher would be in Florida if I recall properly?

Do you think that if dispatching had not been centralized, and CSX dispatchers were still "out in the field", that a local person with a more intimate familiarity with the way the tracks of both railroads are situated, might have been a little more proactive in arranging a precautionary communication with Amtrak? Or is that just wishful thinking?

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Posted by BaltACD on Tuesday, June 11, 2019 9:50 PM

Convicted One
 
Euclid
It registers with me, but apparently not with the NTSB. 

The NTSB's recommendation per the report at your link address appears to me to adequately address the situation "going forward"...unfortunately it's a hard lesson learned...but some are just that.

Question, I guess in order to comply with the NTSB's recommendation, the communication between the two railroads would take place at the "dispatcher" level...correct?

The CSX dispatcher would be in Florida if I recall properly?

Do you think that if dispatching had not been centralized, and CSX dispatchers were still "out in the field", that a local person with a more intimate familiarity with the way the tracks of both railroads are situated, might have been a little more proactive in arranging a precautionary communication with Amtrak? Or is that just wishful thinking?

Wishful thinking!

Amtrak's CNOC (their Dispatching Center) is in Philadelphia, I believe.  When CSX Dispatching was in Baltimore on the BC Desk, the BC Dispatcher did not have any direct communications with Amtrak's CNOC; they did have direct communications with Amtrak's Operater at K Tower in Union Station.  There was no established procedure for the CSX Dispatcher to attempt to notify CNOC of anything happening in the vicinity of F Tower. If there was a known derailment type situation, then the K Tower Operator would be notified of what was taking place. 

In reading through the NTSB report, where the Dispatcher's names were mentioned - these were the same Dispatchers that held those positions when the Dispatcher's Office was in Baltimore.

On 'the other side' QN Tower where trains from the West enter Union Station, Washington Metro operates their right of way between CSX #1 & #2 tracks in a fenced in right of way that is equipped with derailment/intrusion monitors.  The BC Dispatcher has a 'hot line' direct to DC Metro's control center to communicate with Metro about any activations of those sensors.

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Posted by Euclid on Wednesday, June 12, 2019 11:03 AM

Convicted One
 
Euclid
It registers with me, but apparently not with the NTSB.

 

The NTSB's recommendation per the report at your link address appears to me to adequately address the situation "going forward"...unfortunately it's a hard lesson learned...but some are just that.

Question, I guess in order to comply with the NTSB's recommendation, the communication between the two railroads would take place at the "dispatcher" level...correct?

The CSX dispatcher would be in Florida if I recall properly?

Do you think that if dispatching had not been centralized, and CSX dispatchers were still "out in the field", that a local person with a more intimate familiarity with the way the tracks of both railroads are situated, might have been a little more proactive in arranging a precautionary communication with Amtrak? Or is that just wishful thinking?

 

To your question as to how and if CSX will provide protection as was concluded necessary by the NTSB, I don’t have an answer.  Certainly I think it is necessary, and that it ought to be possible regardless of where dispatchers a located and how communication currently exists. However, it would not surprise me if they say it can’t be done.   

Regarding the understanding of what NTSB has said about this issue in their report:  The following are the five relevant quotes of the NTSB report.   I listed the first four of these in the original post above.  I should have included the fifth one that is listed in the following group. 

 

#1)  “The operating crews were not prohibited from walking either on or near the Amtrak tracks.”

#2)  “The NTSB believes that the crew should have been prohibited from walking near the live tracks of the other railroad.”

#3)  “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.”

#4)  “A current process is readily available to provide this protection. For example, a train dispatcher will communicate with another train dispatcher from a different railroad if a derailed train has obstructed an adjacent railroad’s track.”

#5)  “As a result of its investigation, the National Transportation Safety Board makes the following new safety recommendation:

To CSX Transportation and the National Railroad Passenger Corporation:

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.”

 

These points are written in a conversational style with a lot of unrelated material separating them.  I have read through the report at least 25 times, and finally I think I understand these five points that it makes about providing protection.  Originally, I saw several conflicts between them, and they did not seem to logically follow each other.  But now I see that they are subject to multiple interpretations.  Here is the (simplified) final interpretation that I think is what the NTSB intends to say:

  1. Crews are not prohibited from walking on tracks.

  2. NTSB wishes crews were prohibited from walking on tracks.

  3. However, sometimes crews must walk on tracks, so cannot be prohibited.

  4. A current process for protection is available, but not required.

  5. NTSB recommends that the available process of protection be made mandatory, and that CSX forbids fouling tracks without it. 

 

According to that interpretation, it all makes sense right up to and including their recommendation in point #5.

My feeling is that, considering the danger of working so close to very high speed trains that can be upon a person only 5-10 seconds after becoming visible, it is most certainly negligent for CSX to require people to work under this condition.  They should have provided protection in this Ivy City scenario.  Therefore, I believe the probable cause of this accident was CSX sending the employees into danger without protection.  

I believe that factor is the greatest contributing factor in this accident, and that it far exceeds any failure of the two employees to “expect” trains. 

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Posted by Electroliner 1935 on Wednesday, June 12, 2019 5:59 PM

Euclid
My feeling is that, considering the danger of working so close to very high speed trains that can be upon a person only 5-10 seconds after becoming visible, it is most certainly negligent for CSX to require people to work under this condition.  They should have provided protection in this Ivy City scenario.  Therefore, I believe the probable cause of this accident was CSX sending the employees into danger without protection.

Euclid, I sometimes don't agree with you but I think this time, you are SPOT ON. 

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Posted by Convicted One on Wednesday, June 12, 2019 6:25 PM

I feel deeply sorry for the surviving family members of the deceased. This whole thing was a tragic mistake. But I think that all those who insist this should have been prevented are taking benefit of "monday morning quarterbacking"

Don't know if you have ever been involved in any intense litigation, but I have. And it's truly incredible the pointed questions that lawyers can dream up (after the fact) during the discovery phase leading up to a trial. Questions that would never even be pondered under routine circumstances.....yet they are presented in a frame of reference such that they believe  have defacto relevance.

Trying to put myself in the shoes of the victims, I can see how they might have been lulled into a false sense of security walking within their own main up to the point where the front of the stopped CSX train crossed over to occupy that main, leaving them no alternatives other than to climb over a knuckle or veer out into the AMTRAK  track as they did. It's likely I would have made the same decision they did.

I'd like to think that I would have been a little more careful, but going back to my earlier comment to Tree, self assuredness can be intoxicating. Those guys likely felt they were completely in control, and found out otherwise too late.

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Posted by BaltACD on Wednesday, June 12, 2019 7:15 PM

The Conductor lived in the Baltimore-Washington area with his family with his father being a CSX company official.  He graduated from HS in the BW area.  I recall his father seveal times commenting on taking the family to New York on Amtrak for family fun times.  I am certain the Conductor knew the speeds that Amtrak operated through the NEC having ridden it as well as being subject to the news media's reporting of the frequent occurrences of Amtrak hitting and killing trespassers up and down the NEC between Washington and the Delaware line.  He had been working as a Conductor between Cumberland and Baltimore for almost five years.

I cannot comprehend a legitmate reason for the Conductor not to look back - FREQUENTLY - once he and his trainee began walking on Amtrak property.  Being a Qualified Conductor, he knew that he was not on CSX property at that particular location.  That is a question we will never get the answer to - but that answer, or lack thereof is the reason we are having this discussion - irrespective of all the Red Herrings many posters have thrown into the discussion.

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Posted by Paul of Covington on Wednesday, June 12, 2019 10:05 PM

   Instead of the engineers leaning on their horns, I wonder if a series of short blasts (or double toots as used in work areas) by both of them would have made it more apparent that there were two trains.

_____________

   "A stranger is just a friend you ain't met yet."  ___ Dave Gardner

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Posted by charlie hebdo on Wednesday, June 12, 2019 10:10 PM

Paul of Covington

   Instead of the engineers leaning on their horns, I wonder if a series of short blasts (or double toots as used in work areas) by both of them would have made it more apparent that there were two trains.

 

I think that would grab attention better. 

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Posted by Euclid on Wednesday, June 12, 2019 10:16 PM

BaltACD
I cannot comprehend a legitmate reason for the Conductor not to look back - FREQUENTLY - once he and his trainee began walking on Amtrak property. Being a Qualified Conductor, he knew that he was not on CSX property at that particular location.

I assume he did look back, and probably frequently.  How often should he have looked back while walking along the track?  I would say every 5 seconds, look back for one second.  That would seem necessary in a location where a train could come into view an be at your location in as little 5-10 seconds.  So even if repeatedly looking back, there would be a danger of forgetting to look back just once. 

The other main danger that develops is the approach of the train from ahead of them.  That train would tend to be a great distraction because it triggers all your defenses to make sure you are clear of it.  It could easily absorb all of a person's attention, and at the moment, the person would forget about looking back. 

In looking back, the person is surely aware of the danger of a train approaching from behind.  I don't think they are likely to just forget that danger.  But when they spot a train coming toward them, they might mentally move that danger from behind to danger from ahead, and completely overlook the unlikely event of the danger behind doubling to include danger from ahead. In a way, it is not the train behind that sneaks up on you.  What sneaks up on a person is the illusion that two trains are one.

Regarding the use of short horn blasts, that is what the rules call for; a series of short blasts in succession.  Leaving some holes in the sound, would leave room for each train horn to separate from the other, and perhaps that may have been noticed by the two conductors.

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