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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by 243129 on Tuesday, July 23, 2019 3:54 PM

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243129

A perfect storm of events created this tragedy. Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer. CSX and Amtrak also bear responsibility for this tragedy

 

 

 

What did the engineer of Amtrak #175 do wrong?

 

Read her testimony here and if you have any operations knowledge her errors will be self evident. If you were not employed in railroad operations I will be happy to explain. Here is a preview:

"When I start seeing them, I start inching to full service.

Q. Okay. I'm just taking some notes here, just what you said. So you said you were in suppression when you saw them. And then you started inching towards full service --

A. Yes. 

Q. -- after seeing them and blowing the horn simultaneously.

A. Yes.

Q. And did you ever place your train in emergency?

A. Yes.

Q. And did -- when did you do that?

A. Once I struck"

The full interview:

https://dms.ntsb.gov/pubdms/search/document.cfm?docID=470819&docketID=62103&mkey=95451

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Posted by zardoz on Saturday, July 20, 2019 11:58 AM

Euclid
Most of the details come from the interviews of the engineers of #66 and #175.  Although it is somewhat difficult to assimilate because the interview testimony is so cryptic with unfinished sentences that might be enough in a direct conversation.  I have read both interviews, but now I am just going by memory.  I may go back and review them again.  Generally, it seems that both trains passed each other almost at the exact location of the two conductors.  The engineer of #66 said he witnessed the two conductors being struck by #175, so he had to be short of the actual passing point when they were struck in order to see that. 

Euclid, thanks for the clarification.

Geez, the visual and emotional intensity is bad enough when you're about to stike a car or a pedestrian; at least the actual impact is hidden from view by the nose of the locomotive (although sometimes you have to go under the locomotive and extract body parts for the Coroner). But the poor Engineer of #66--he got to see everything close-up. I bet his memories of the event will never fade.

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Posted by Euclid on Friday, July 19, 2019 8:54 PM

It is obvious that had they not been on the track, they would not have been hit.  But the accident raises other questions and issues that are not so obvious.  In an accident like this, investigators will look at anything that could have prevented it, and not just stop looking after the simplest and most obvious cause is found. 

Two trains sounding like one and thus having the danger warning of the horn negated just when it is needed most is not obvious at all.  Even when clearly explained I doubt that many people make the effort to grasp the concept in a way that they can relate to that experience.  I don’t think that the three engineers understood that element.  Surprisingly, the NTSB understood it perfectly and described it as well as it has ever been described.

I can understand the two conductors walking on the Amtrak side if there was a water-filled ditch on the non-Amtrak side.  But what I can’t understand is why they walked on the ends of the ties rather than on the ballast between the Amtrak track and the CSX track.  The concrete tie ends on the Amtrak track slope downward as they extend out from the rail.  It looks like maybe a 10 degree slope.  Aside from the train danger, why would anyone choose to walk on the sloping ties rather than on the flat crushed rock ballast?  It makes me wonder if there is more to the explanation of what happened. 

Consider this possible scenario:  They were walking on the ballast in the clear between the two tracks.  Then when they saw #66 approaching, they could not be sure which track it was on, and if it was on the track nearest the CSX track, they did not want to be in that narrow space between the CSX train and #66.  Maybe it appeared to them that #66 was on the track nearest CSX, and so they suddenly made a snap decision to run across both Amtrak tracks in front of #66 in order to get in the clear with more space on the south side of the two Amtrak tracks.  In the panic of that dash, they forgot to look east to see #175 approaching.

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Posted by Euclid on Thursday, July 18, 2019 11:40 AM

zardoz
 
Euclid
The proper horn signal in this type of emergency is a series of short horn blasts.  This would have made it much more likely for the victims to be able to notice that there were two horns at work.  With a series of short blasts, it would not be possible for the two signals to perfectly match their timing.  If the horn signals failed match timing, it would have been more noticeable that there were two horns instead of one.  That would be the most beneficial horn warning effect.  It is exactly opposite of the effect of both engineers “laying on the horn.” Nevertheless, both engineers laid on the horn as though they believed more horn is better.  Actually, if the engineer of #66 never blew the horn, I am certain that the two conductors would have realized the horn they were hearing was behind them. 

 

Presuming that the sequence of events you mention is correct (I don't want to reread the report), I am wondering if the Engineers of both trains could see each other prior to impact. If yes, then what you say is correct; if not, then without knowing of the conflicting movement, there might be a tendency to "lay on the horn" (a panic reaction) instead of doing short blasts.

 

It's similar to when you see animals on the tracks, expecially deer. The normal reaction is to "lay on the horn" in the hope of scaring them away. But a deer-in-the-headlights situation requires not only to do short blasts, but also to dim or extinguish the headlight at the same time--something that takes a bit of practice to do in a 'panic'.

Being able to ascertain in an instant regarding the proper action to take is a talent that improves with experience.

 

Zardoz,

Most of the details come from the interviews of the engineers of #66 and #175.  Although it is somewhat difficult to assimilate because the interview testimony is so cryptic with unfinished sentences that might be enough in a direct conversation. 

I have read both interviews, but now I am just going by memory.  I may go back and review them again.  Generally, it seems that both trains passed each other almost at the exact location of the two conductors.  The engineer of #66 said he witnessed the two conductors being struck by #175, so he had to be short of the actual passing point when they were struck in order to see that.  I get the impression that he may have been less that 50 ft. away from the two conductors when they were struck.  He said he saw it clearly, wereas the engineer of #175 was not able to see as much, if anything.

Both engineers said they saw the two victims, seemingly for their whole view range, prior to #175 striking them.  The victims were wearing green safety vests and carrying lanterns.  The two engineers seemed differ in their conclusions of where the two conductors were walking.  One said they were walking on the outside ends of the ties, while the other said they were walking inside of the gage. 

In looking at the event recorder report for the locomotive of #175, it appears that the engineer blew the horn continuously from the time the locomotive rounded the curve and had a clear view of the conductors until the train hit them.  This would have been approx. 10-15 seconds based on the train speed which was 74 mph.

As I recall, the engineer of #66 also said that he laid on the horn in a similar sequence of approach and speed as #175.  So basically, both engineers had a clear view of the opposing train and of the two conductors for the entire visual range of approach. 

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Posted by charlie hebdo on Thursday, July 18, 2019 11:35 AM

Overmod

 

 
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According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks."

 

This being contradicted explicitly both by the actual event-recorder download and the actual text of the engineer interview in the docket.

Unless you embrace sophistry and  interpret the sentence "the Amtrak engineer responded quickly with an increasing partial brake application, and applied emergency braking upon hitting the CSX employees walking near the tracks," which is what the record substantiates.  I cannot believe this sentence construction is not intentional, although I refuse to speculate on the reason(s) for it.

 

I was only posting the paragraphs to which he referred for clarity. 

My opinion is that no one,  railroad workers or public,  should ever walk on a busy,  95mph track without permission being obtained. 

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Posted by BaltACD on Thursday, July 18, 2019 11:29 AM

Deggesty
Balt, the announcement showed up in my email, but not on the Trains site. I hope all of our self-appointed experts apply for this position, so they will have authority behind their statements.

I got it from the banner ad that displays on the Trains Forum page when I call up the forum.

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Posted by Deggesty on Thursday, July 18, 2019 11:23 AM

Balt, the announcement showed up in my email, but not on the Trains site. I hope all of our self-appointed experts apply for this position, so they will have authority behind their statements.

Johnny

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Posted by BaltACD on Thursday, July 18, 2019 10:20 AM

Job opening for our self announced experts

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Posted by Euclid on Thursday, July 18, 2019 9:04 AM

In the interview, the engineer said she applied emergency braking immediately upon striking the two conductors.  She first saw the two men about 10-15 seconds earlier and did not apply emergency braking during that approach time frame. 

In the interview, she said she expects people to normally move out of the way before being struck.  An engineer who expects that, and relies on that expectation will not make an emergency application until they strike the person (or vehicle). 

This avoids the chance of going into emergency for a reason that goes away before impact, and thus renders the emergency application to have been made for no reason.  The reasoning by these engineers is often that they could not have stopped short of the collision even if they did make the emergency application as soon is the fouling was spotted.  This of course, is flawed logic.

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Posted by zardoz on Thursday, July 18, 2019 8:36 AM

Euclid
The proper horn signal in this type of emergency is a series of short horn blasts.  This would have made it much more likely for the victims to be able to notice that there were two horns at work.  With a series of short blasts, it would not be possible for the two signals to perfectly match their timing.  If the horn signals failed match timing, it would have been more noticeable that there were two horns instead of one.  That would be the most beneficial horn warning effect.  It is exactly opposite of the effect of both engineers “laying on the horn.” Nevertheless, both engineers laid on the horn as though they believed more horn is better.  Actually, if the engineer of #66 never blew the horn, I am certain that the two conductors would have realized the horn they were hearing was behind them. 

Presuming that the sequence of events you mention is correct (I don't want to reread the report), I am wondering if the Engineers of both trains could see each other prior to impact. If yes, then what you say is correct; if not, then without knowing of the conflicting movement, there might be a tendency to "lay on the horn" (a panic reaction) instead of doing short blasts.

It's similar to when you see animals on the tracks, expecially deer. The normal reaction is to "lay on the horn" in the hope of scaring them away. But a deer-in-the-headlights situation requires not only to do short blasts, but also to dim or extinguish the headlight at the same time--something that takes a bit of practice to do in a 'panic'.

Being able to ascertain in an instant regarding the proper action to take is a talent that improves with experience.

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Posted by Overmod on Thursday, July 18, 2019 8:30 AM

charlie hebdo
According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks."

This being contradicted explicitly both by the actual event-recorder download and the actual text of the engineer interview in the docket.

Unless you embrace sophistry and  interpret the sentence "the Amtrak engineer responded quickly with an increasing partial brake application, and applied emergency braking upon hitting the CSX employees walking near the tracks," which is what the record substantiates.  I cannot believe this sentence construction is not intentional, although I refuse to speculate on the reason(s) for it.

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Posted by charlie hebdo on Thursday, July 18, 2019 7:30 AM

243129
Let us start with the NTSB and their contradictory report which I called to their attention to and they have not corrected. https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf  

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

Quotes cited for clarity.

Page 4, paragraph one: "After the impact, at 11:18 p.m., the engineer placed the train into emergency braking, announced emergency three times on the radio, and called the Amtrak dispatch center via the radio."

Page 6, paragraph six:  "On the day of the accident, she [engineer of train #175] departed New York Penn Station at 8:06 p.m. According to the event recorder and the engineer interview, the Amtrak engineer responded immediately and applied emergency braking upon seeing the CSX employees walking near the tracks."

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Posted by MMLDelete on Wednesday, July 17, 2019 11:14 PM

243129

A perfect storm of events created this tragedy. Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer. CSX and Amtrak also bear responsibility for this tragedy

 

What did the engineer of Amtrak #175 do wrong?

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Posted by 243129 on Wednesday, July 17, 2019 8:16 PM

Convicted One

I must say that I am quite impressed. This thread is now 15 pages long, and not one mention of the Darwin award.  Some of you are finding compassion in old age, perhaps?

 

There are many Darwin Awards to be handed out. Let us start with the NTSB and their contradictory report which I called to their attention to and they have not corrected.

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

 

I call your attention to page four, paragraph one, third to the last sentence of NTSB report RAB-1901.

Secondly I call your attention to page six, paragraph six, the last sentence.

 

 

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Posted by Convicted One on Wednesday, July 17, 2019 7:17 PM

I must say that I am quite impressed. This thread is now 15 pages long, and not one mention of the Darwin award.  Some of you are finding compassion in old age, perhaps?

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Posted by 243129 on Wednesday, July 17, 2019 6:48 PM

tree68

And to think - the simple expedient of not walking on the ends of the ties of a 95 MPH mainline (with their backs to the current of traffic) would have prevented it.

 

Yup.

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Posted by tree68 on Wednesday, July 17, 2019 3:47 PM

And to think - the simple expedient of not walking on the ends of the ties of a 95 MPH mainline (with their backs to the current of traffic) would have prevented it.

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Posted by Euclid on Wednesday, July 17, 2019 2:43 PM

It was indeed a perfect storm, in the sense that necessary ingredients needed to come together at the same time, and that being relatively unlikely.  The main set of ingredients was the simultaneous convergence of two trains at the precise location of two people who were not wary enough to expect that.  Then, the first train they saw absorbed all their attention and none was left to at least accidentally notice the second train at the same time that it was becoming more obvious as it drew closer.

Had #66 not arrived at the site the same moment as #175, I don’t believe there was a chance that the two victims would have been struck.  Also, had the two Amtrak engineers not “laid on the horn” over the final approach, there is a very good chance that the two victims would have realized that there were two trains approaching instead of one.  The distraction affecting the two victims might have been obvious to any alert engineer who spots people who fail to move while seeming oblivious to an approaching train. 

The last thing that should be done is for both engineers to lay on the horn; as if the problem is that the horn is not loud enough to get the attention of the people on the track.   The horns were loud enough to be heard a mile away.  Obviously the two conductors heard both horns loud and clear.  But the laying on the horn by both engineers for the entire 10-15 seconds of their approach guaranteed that the two victims would here the two horns as being one.  And as they attributed this to only #66, their attention became riveted on that train as they perhaps wondered why the unusually long horn blast.  Drawing their attention to #66 diminished the possibility that they would suddenly perceive that #175 was sneaking up behind them.

The proper horn signal in this type of emergency is a series of short horn blasts.  This would have made it much more likely for the victims to be able to notice that there were two horns at work.  With a series of short blasts, it would not be possible for the two signals to perfectly match their timing.  If the horn signals failed match timing, it would have been more noticeable that there were two horns instead of one.  That would be the most beneficial horn warning effect.  It is exactly opposite of the effect of both engineers “laying on the horn.”

Nevertheless, both engineers laid on the horn as though they believed more horn is better.  Actually, if the engineer of #66 never blew the horn, I am certain that the two conductors would have realized the horn they were hearing was behind them.  So they would have gotten out of the way. 

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Posted by AnthonyV on Sunday, July 14, 2019 11:15 AM

243129

A perfect storm of events created this tragedy. Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer. CSX and Amtrak also bear responsibility for this tragedy

 

I think that sums it up perfectly.

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Posted by 243129 on Sunday, July 14, 2019 11:02 AM

A perfect storm of events created this tragedy. Poor vetting ,poor training , poor supervision, and lack of common sense coupled with inexperience and bad decisions on the parts of the CSX crew and Amtrak 175  engineer. CSX and Amtrak also bear responsibility for this tragedy

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Posted by Euclid on Wednesday, July 10, 2019 9:09 PM

In the engineer’s interview, he explains things as though they might be possible reasons for the two conductors not walking back on the north side of the track, which he deems to be safer than the south side because the south side abuts the dangerous Amtrak track. 

He said he was not expecting them to walk on that south side due to the heightened danger.  He also said that he never said anything to warn them not to walk on the south side.  They he gave an example of what he might have said as a warning to them.

He also said that walking on the south side would have required protection, and that he was not sure if protection could have been obtained; and that he did not know how to go about the process of obtaining protection.  However, because he assumed they would be walking on the north side, it also assumed that protection would not be necessary.    

In this same line of discussion about why the two conductors walked on the dangerous south side, the engineer refers to there being a ditch on the north side of the CSX tracks, which is the non-Amtrak side, but he seems to stop short of what he intended to say.  He said there was a ditch and ballast, and then he stopped as though he had more to say about it but did not say it. 

However, by connecting the two issues of a ditch and ballast; it seems to me that his point was that ballast was steeply sloped downward, away from the track and that it continued downward into the lower elevations leading down into the ditch.  In other words, the ballast was a difficult walking surface because it sloped downward.  Then instead of the down-sloping ballast ending shortly and reaching a level roadbed, it continued sloping until the level walking surface was the bottom of a ditch.   

Then, in covering this same subject matter for subsequent interviewer, the engineer refers to there being a ditch filled with water on the north side of the track. 

It seems to me that the point of first mentioning the ditch and the ballast, and then adding that the ditch was filled with water, is this point:  The two conductors did not walk on the north side because the steep ballast sloping down into a ditch filled with water would have been difficult, treacherous, and unpleasant to walk on.   It apparently was steeply sloped, loose rock ballast from the side of the CSX train down to a water-filled ditch.  It seems to me that this could very well explain why the two conductors chose to walk on the Amtrak side rather than fight this very difficult terrain of the north side.   

Also, this water-filled ditch and steep ballast is not at all apparent in the two photos of the head end of the CSX train viewed looking at it near head-on.  In those photos, the ground on the north side of the train is wide and flat with a service road on it.  Apparently, those features end before reaching back to the location where the conductors decided to walk on south side. 

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Posted by ChuckCobleigh on Tuesday, July 9, 2019 3:46 PM

Just checked in to see how the horse was doing.

Not well, it would seem.

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Posted by BaltACD on Monday, July 8, 2019 10:06 PM

Too bad you could not understand what you read Bucky.

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Posted by Euclid on Monday, July 8, 2019 9:27 PM

In reviewing the interview with the CSX engineer, it seems clear that the two conductors were inspecting both sides of the train at the time it was stopped at the accident site.  They were not just walking forward after riding the cars up from the first location the train had stopped earlier. 

So at that second location at which the train stopped, the two conductors got off, one on each side, and the train pulled past them as they inspected it.  Then after their inspection, they walked forward together on the Amtrak side. 

The engineer does state that he was surprised that they walked up together on the Amtrak side, considering the heightened danger posed by Amtrak.  Also, the engineer could not have known whether they were walking in the clear of the Amtrak track or if they were walking in the Amtrak foul zone.  So apparently, the engineer felt that the Amtrak side was too dangerous to walk on, even if in the clear of the Amtrak foul zone.   

The engineer also says that when they first got off the engine to start the inspection, the trainee conductor got off on the non-Amtrak side and the senior conductor got off on the Amtrak side.  The engineer stated that, at the time they got off the engine, he thought that the senior conductor chose to get off on the most dangerous side (because of nearness to Amtrak) because he had more experience to deal with that heightened danger. 

So, what this information indicates is that the engineer feels that the Amtrak side was too dangerous to walk on, but not too dangerous to perform the required inspection work on.  How can that be reconciled?  It seems to me that if it is too risky to walk there, it is too risky to work there.

Overall, the engineer did have a clear understanding that the one or both conductors would be performing inspection work on the Amtrak side of the CXS train, but he did not determine that protection should have been requested and obtained. 

If protection was required, or even just available, but not required, it seems natural that the engineer and conductors would have requested it, given the engineer’s interview comments about how they used an informal type of 3-step protection for fouling the CSX train in such activity as releasing handbrakes.  They had a discussion about how they would use a system that basically performed 3-step protection without the actual formal 3-step protection being available on CSX. 

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Posted by charlie hebdo on Saturday, July 6, 2019 10:07 PM

tree68

Let's face it folks, until we all agree that the two crewmen were totally blameless in their own deaths, and that the fault rests solely with CSX (and to some extent Amtrak), Bucky will not be satisfied.

 

I concur.  Time to stop feeding his internal dialogue. 

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Posted by BaltACD on Saturday, July 6, 2019 7:50 PM

They were trying to telepathically contact Bucky as they walked.  Attempt was not successful.

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Posted by Euclid on Saturday, July 6, 2019 5:22 PM

Euclid

As I mentioned on the previous page, I want to isolate the actual rules broken by the two victims; as opposed to various opinions about how advisable their activities were. 

So, I have established that there was no rule, special instruction, or any type of company edict that prohibited the two employees walking on the Amtrak track.

Also, there was no rule, special instruction, or any type of company edict that required the two employees to have protection while walking on the Amtrak track.

Their actual rules violation is addressed in the CSX Safe Way rules, which can be found at this link:

https://www.dot.ny.gov/main/business-center/designbuildproject/repository/CSXT_Safeway_2012_07-01.pdf

Refer to these quotes from the CSX Safe Way rules:

 

GS-10. On or About Tracks

When working on or about tracks:

• Apply the appropriate protection (3 –Step, Roadway Worker, Blue

Signal, etc.) for your job classification where required.

Be alert for and keep clear of the movement of cars, locomotives, or

equipment at any time, in either direction, on any track.

• Do not cross within 25 feet of the end of standing cars, equipment, or

locomotives, except when proper protection is provided.

• Stand at least:

- 30 feet or more from a switch or derail associated with the route of

passing equipment, when practical.

- 10 feet or more from a switch or derail being traversed by

equipment during switching operations when practical.

• Stop and look in both directions before making any of the following

movements:

- Fouling or crossing a track.

- Moving from under or between equipment.

- Getting on or off equipment.

- Operating a switch.

• You may cross more than one track without stopping at each track if you

determine it is safe to do so.

 

The only rule that the two employees violated was the one I highlighted in red:

Be alert for and keep clear of the movement of cars, locomotives, or equipment at any time, in either direction, on any track.

 

We know that they violated that rule during the last ten seconds of their lives. 

That is the extent of their rules violation that we know of.

 

The above quote is what I actually said and believe to be true.   

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Posted by Deggesty on Saturday, July 6, 2019 5:04 PM

Larry, I believe you are a real prophet.

Johnny

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Posted by tree68 on Saturday, July 6, 2019 5:00 PM

Let's face it folks, until we all agree that the two crewmen were totally blameless in their own deaths, and that the fault rests solely with CSX (and to some extent Amtrak), Bucky will not be satisfied.

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Posted by Euclid on Friday, July 5, 2019 10:01 PM

BaltACD
 
Euclid
 
BaltACD 
Euclid 
BaltACD

All the protections in the world are defeated by those who decide, for whatever their reasons, not to use it. 

As long as the final decision is in the hands of the individual - his will, will prevail. 

All the protections in the world are NOT defeated by a person who decides not to use protection.  The only protection that is defeated is the protection that the person decided not to use.  For everyone else, the protections continue. 

There are safety rules and guards all over the place.  Most people comply with them because they realize the danger that the rules address; and because they don’t want to get fired for not following the rules.  Also, many of the rules inform people of the danger that they might not realize without that information.  So I don’t understand your point which seems to be that all rules are worthless because some people will ignore them.   Most people will follow the rules, and the rules will prevent injuries and save lives.   What’s wrong with that?   

The point being, the deceased did 'what THEY thought was the right thing under the circumstance that THEY viewed at the time THEY viewed them'.  They were wrong. 

Well sure, that can happen.  I thought your were finding a flaw with rules when you started by saying, "All the protections in the world are defeated by..."

Now had the two conductors been governed by a rule requiring them to obtain protection, I feel confident that they would have done so, and it would have saved their lives. 

 

Until we can download their final thought train we will never know.  They may have pondered a number of actions supported by the rules that were in effect at the time - and then they said 'F it'.  You don't know, I don't know and we will never know.

 

The only rule that applied was to be alert for trains.  Protection would have kept the trains away from them.  I am confident that if protection was required by a rule, they would have complied. 

If they only had #175 coming up behind them, and no #66 coming at them; and then if they did not get out of the way, I would say yes we would need to know their thoughts to understand why on earth they did not move out of the way.  But under the actual circumstances of the two trains, I think what happened is perfectly understandable without knowing what they were thinking. 

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