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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by charlie hebdo on Friday, June 14, 2019 12:12 PM

Overmod

 

 
Euclid
I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  [...]  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

 

The problem with this whackjob kind of rationalization is that it completely ignores either the actual premise or the actual purpose of the rule.

Let's look at the exact analogue of this rule for firearms, the one that in the NRA rhyme begins "Sonny, never let your gun/Pointed be at anyone."

You'd be saying there's no reason to use care not to point a loaded gun at paths because you don't think there would be people there that time of day.  And perhaps at least some of the time, you'd be right -- but you can no more know that than, let's say, you can know whether prompt emergency braking would provide just the right additional 1/4 second of reaction time.  Your 'advice' there is just as applicable here:

You never relax vigilance for a moment if you're even close to fouling a track.  Any time.  Any where.  And you observe that as a rule, even if 'common sense' tells you there isn't a 'predominance of evidence' that you "need" to.  The whole point of the rule being to assure 100% effective vigilance as a habitual reflex.

That evidently wasn't 'trained' (or, to troll a little, wasn't 'vetted for') adequately for the conductor and trainee in question.  Had the simple rule of 'expect a train in any direction, at any time' been the habit it must be on the railroad, there is no question at all they wouldn't have died as they did.

 

In support of your analogy, there is another,  tighter one most of us learn when young.  If walking down a road with no sidewalk, walk on the side facing traffic.  Don't walk with the flow because you might not notice a vehicle approaching from behind until it's too late. 

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Posted by Overmod on Friday, June 14, 2019 11:32 AM

NDG
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.

Can you explain to me how frequent it is that you'd try to move a drawbar toward alignment from the 'danger zone' by grasping the knuckle or pushing the 'inside' of the engagement zone?  Does it save that much time when 'both' the knuckle is closed and the drawbar misaligned over?

Because that's likely what happened there: him reaching in from the side to pull the knuckle, then shifting to pull or push the drawbar as a continuation -- not to be cruel but you could probably tell which it was by the amount of 'above the wrist' that was left unsquashed.

Makes me wonder, again, if there is some kind of modern analogue to a Bishop coupling knife that would let you do both opening a knuckle and pushing/pulling a drawbar to alignment conveniently from completely outside the 'engagement zone'

Not to mention the likely bloodstain ... and worse ... under the dusting of new snow.

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Posted by Overmod on Friday, June 14, 2019 11:25 AM

Euclid
I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  [...]  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

The problem with this whackjob kind of rationalization is that it completely ignores either the actual premise or the actual purpose of the rule.

Let's look at the exact analogue of this rule for firearms, the one that in the NRA rhyme begins "Sonny, never let your gun/Pointed be at anyone."

You'd be saying there's no reason to use care not to point a loaded gun at paths because you don't think there would be people there that time of day.  And perhaps at least some of the time, you'd be right -- but you can no more know that than, let's say, you can know whether prompt emergency braking would provide just the right additional 1/4 second of reaction time.  Your 'advice' there is just as applicable here:

You never relax vigilance for a moment if you're even close to fouling a track.  Any time.  Any where.  And you observe that as a rule, even if 'common sense' tells you there isn't a 'predominance of evidence' that you "need" to.  The whole point of the rule being to assure 100% effective vigilance as a habitual reflex.

That evidently wasn't 'trained' (or, to troll a little, wasn't 'vetted for') adequately for the conductor and trainee in question.  Had the simple rule of 'expect a train in any direction, at any time' been the habit it must be on the railroad, there is no question at all they wouldn't have died as they did.

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Posted by mudchicken on Friday, June 14, 2019 7:26 AM

LO: TAWS didn't work / won't work...In the end, the senior conductor (actually both) broke more than one cardinal rule and paid the consequences. The dimestore lawyers can continue to argue, but sad case - closed.

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 13, 2019 11:33 PM

tree68
 
Euclid
They heard the horns of both trains, but it appears they thought they were only hearing the horn of #66.

 

A slight correction, based on the official report.  

In the end, they didn't have their heads on a swivel, as they should have.  A primary rule of railroading:  Always expect a train.  They apparently didn't, and we all know the result.

 

What correction?  What you quoted from me is true.

I don’t think it is as simple as failing to expect trains.  It may not have been that at all.  Back on page 1, Balt seemed to say he assumed the conductors never looked back, and he could not understand why.  I mentioned to him that I assume they did look back.  But apparently they did not look back during the approach of #175.    They may not have looked back often enough.  How often should a person look back? It would have to be often enough to not exceed the time interval between a train coming into view and reaching the employees at whatever speed the train was moving.  Having your head on a swivel sounds nice, but what does it really mean?  What is really needed is eyes in the back of your head and in front.

I told Balt that I thought a reasonable swivel routine would be to look back for one second at 5-second intervals.  Is that a head on a swivel? I think the two conductors were competent and responsible.  Maybe they broke a rule, but certainly, they encountered a set of unusual circumstances that totally absorbed all their attention, making them oblivious to the danger approaching from behind.  This probably happened without their conscious realization that their attention had been partly lost. 

They were expecting trains and they probably believed the one they saw approaching was one they were expecting. They saw the front approaching train (#66) and heard its loud horn warning.  They knew they were in the clear of it. They were not expecting a train from the rear because they had been checking periodically and were hearing full time without detecting a train.  When they heard the loud horn, they assumed it was only #66, and they did not know it was also #175 with the two horn sounds merged.  As their attention became riveted on #66, they assumed their hearing was still protecting them from behind, so they were not expecting #175 coming up behind them.       

I would not jump on their case for causing their demise by breaking a rule requiring people to always expect trains.  Rule 10 requires employees to look both ways before walking across a live track.  When you cross a live track you look both ways to see if it is clear.  If clear, you foul the track as you cross.  During that crossing, you are not expecting a train because you know it is clear.  If you were actually expecting a train as the rule requires, you would not cross.  So, “always expect a train” allows some discretion to know whether there is a reason to expect a train.

So an employee walks down a track and occasionally looks back to make sure a train is not approaching.  An employee also knows they have the sense of hearing and trains make some noise.  The employee knows whether train noise will be prominent or muffled by wind, fallen snow, etc., and they allow for that.  Like making a crossing, an employee walking down the track between looks-back is not expecting a train.  He can’t be expecting a train if he is on the track.

Rule 10 requires employees to look both ways before walking across a live track.  It says nothing about how to maintain such a precaution when walking along a track.  It says nothing about having your head on a swivel or how often to look back.

Given these circumstances, I would not conclude that the employees broke any rules.  I don’t believe that getting struck by a train proves that the victims failed to expect trains.  By far, the more egregious offense in this case was the CSX sending employees into tight quarters bordering on the foul zone of 125 mph trains without protection.

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Posted by MMLDelete on Thursday, June 13, 2019 9:25 PM

It seems to me there should be a large red or orange “hot button” which activates a sound very much unlike any other (and expected) sound. I like the above suggestion of the European police siren.

But here is my wrinkle. The button is switchable, and it can produce two very different unexpected noise. From my experience, trains on a line always have a “direction.” Despite the actual directions in a given spot, a line will have, for example, northbound and southbound trains.

Each time an engineer goes on duty, he/she is required by rule to set the hot button for either NB or SB duty, and record/report that this was done. This way, the two Amtrak trains at Ivy City would have been making TWO VERY DIFFERENT unusual noises. A person would be much more likely to discern that two different trains are approaching.

Considering the cost of a locomotive, this feature would be a tiny drop in the bucket.

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Posted by tree68 on Thursday, June 13, 2019 8:31 PM

Euclid
They heard the horns of both trains, but it appears they thought they were only hearing the horn of #66.

A slight correction, based on the official report.  

In the end, they didn't have their heads on a swivel, as they should have.  A primary rule of railroading:  Always expect a train.  They apparently didn't, and we all know the result.

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Posted by blue streak 1 on Thursday, June 13, 2019 8:01 PM

What about the sound of european emergency vehicles?  The 2 two note up and down is completely different than present horns.  Might just take a single bell horn only activated alternately with the regular horn.  Still does not solve the problem of two trains at once.  

Any thoughts from our CHI people? 

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Posted by Euclid on Thursday, June 13, 2019 7:40 PM

Overmod
Charlie - do you have thoughts on a correct methodology to design alert sounds for the particular situation posed by the Ivy City tragedy?

I don't see a connection in preventing the Ivy City accident with louder horns.  The conductors were not struck because they failed to hear the horn.  They heard the horns of both trains, but they thought they were only hearing the horn of #66. 

The Amtrak horns were plenty loud enough to cut through the background noise.  You can make the horns ten times louder, but if two trains blow them at the same time, bystanders are still likely to think they are hearing just one train as they get runover by the second one.

What is needed in a situation like at Ivy City would be a way for the engineer of #175 to turn off the horn of #66.  That would have undoubtedly prevented the accident. 

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Posted by BaltACD on Thursday, June 13, 2019 6:49 PM

tree68
 
Overmod
There may be some Progress documentation about why they build and tune their horns that way. 

I'm pretty sure all locomotive manufacturers buy their horns "off the shelf."  

There is some discussion of design specs on Ed Kapriski's horn site: http://www.dieselairhorns.com/collection.html

Listening to a site like the Deshler diamond on YouTube will introduce one to the wide variety of horn sounds that result from time and lack of maintenance.

Least we forget - SOUND is greatly influenced by the wind.

If the wind is blowing from the origin of the sound - it will sound like it is right on top of you.  If it is blowing away from the orign of the sound - you may not even hear it.  If the wind is blowing hard enough, you may only hear the wind no matter where the warning sound originates.

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Posted by tree68 on Thursday, June 13, 2019 6:39 PM

Overmod
There may be some Progress documentation about why they build and tune their horns that way.

I'm pretty sure all locomotive manufacturers buy their horns "off the shelf."  

There is some discussion of design specs on Ed Kapriski's horn site: http://www.dieselairhorns.com/collection.html

Listening to a site like the Deshler diamond on YouTube will introduce one to the wide variety of horn sounds that result from time and lack of maintenance.

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Posted by Convicted One on Thursday, June 13, 2019 6:30 PM

Perhaps those old Chrysler air raid sirens from the early days of the cold war might get some attention?

Dedicated Hemi engine to power them.

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Posted by charlie hebdo on Thursday, June 13, 2019 4:51 PM

Overmod

To get this steered back to charlie's reasonably verifiable sources: there is some work on maximum alarm volume (some in nuclear power, some in aircraft warning systems) and some about relative loudness and prioritization when there are multiple alarms that have to be discriminated in realtime (as in a damaged aircraft or recovery from severe CAT).

There was at least a discussion of effective measured SPL at grade crossings in the research that led up to wayside horns, and some more in how to design and orient the waysides for 'best' effect.

GM had to have done some careful experimentation into alarm sounds to come up with the coolant alarm in the last-generation heavy Eldorados in the '70s; I have experienced the alarms in the control room at TMI 2 and that little GM device under the dashboard is more alarming!  If starting to research an electronically-generated critical-alert tone I'd start with that.

Charlie - do you have thoughts on a correct methodology to design alert sounds for the particular situation posed by the Ivy City tragedy?

 

Sorry but that's not in my wheelhouse, to use a moth-eaten phrase. 

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Posted by Overmod on Thursday, June 13, 2019 4:45 PM

Since I have reading rights at the UofM cognitive science library I will check to see what is recent on the science of critical alert systems.  I can't guarantee anything but it's a start.

The first place I actually heard  132-dB horns fired in anger, and intentional dissonance a la the mid-70s revision of the Energency Broadcast System alert (before the modem warble tones were included) was on KCS through Bossier City in the late 1980s.  Those trains were miles away, moving at a right angle, but sounded only a block or so over; it is inconceivable that anyone at a grade crossing with AC on and music playing wouldn't hear it.  Only recently has this 'design practice' come back into conscious use, on late production EMDs.  There may be some Progress documentation about why they build and tune their horns that way.

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Posted by Overmod on Thursday, June 13, 2019 4:33 PM

To get this steered back to charlie's reasonably verifiable sources: there is some work on maximum alarm volume (some in nuclear power, some in aircraft warning systems) and some about relative loudness and prioritization when there are multiple alarms that have to be discriminated in realtime (as in a damaged aircraft or recovery from severe CAT).

There was at least a discussion of effective measured SPL at grade crossings in the research that led up to wayside horns, and some more in how to design and orient the waysides for 'best' effect.

GM had to have done some careful experimentation into alarm sounds to come up with the coolant alarm in the last-generation heavy Eldorados in the '70s; I have experienced the alarms in the control room at TMI 2 and that little GM device under the dashboard is more alarming!  If starting to research an electronically-generated critical-alert tone I'd start with that.

Charlie - do you have thoughts on a correct methodology to design alert sounds for the particular situation posed by the Ivy City tragedy?

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Posted by BaltACD on Thursday, June 13, 2019 4:04 PM

charlie hebdo
 
BaltACD 
charlie hebdo
Tangential,  but related is the current practice of locomotive horns. Could  their field be narrowed to be more unidirectional?  Is there research to support the db level used,  which seems much louder than in the late days of steam and first and second generation diesel?  Is dash dash dot dash the best way to signal level crossings or is it just a tradition not used in many other countries? 

Take your pick

https://www.youtube.com/watch?v=mMkJc3xsYC4

 

Based on research,  if any exists. 

Based on existance - everyone forms their own 'science' where warnings are concerned.

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Posted by charlie hebdo on Thursday, June 13, 2019 2:38 PM

BaltACD

 

 
charlie hebdo
Tangential,  but related is the current practice of locomotive horns. Could  their field be narrowed to be more unidirectional?  Is there research to support the db level used,  which seems much louder than in the late days of steam and first and second generation diesel?  Is dash dash dot dash the best way to signal level crossings or is it just a tradition not used in many other countries?

 

Take your pick

https://www.youtube.com/watch?v=mMkJc3xsYC4

 

Based on research,  if any exists. 

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Posted by rdamon on Thursday, June 13, 2019 2:20 PM

Where is Alonzo Billups when we need him :)

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Posted by Euclid on Thursday, June 13, 2019 1:22 PM

There two different problems: 

  1. The problem that caused the Ivy City accident.

  2. The problem of warnings unable to grab attention. 

It is easy to solve #2 by just throwing out a bigger warning, but that would not have prevented #1.

No, the problem of #1 is much more finessed.  Nobody had trouble hearing the warning.  If #66 had not blown its horn, the two conductors would likely have heard the horn of #175 and realized it was coming up behind them, and there would have been no accident.  If #66 was not approaching, there would have been no accident. 

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Posted by BaltACD on Thursday, June 13, 2019 12:46 PM

charlie hebdo
Tangential,  but related is the current practice of locomotive horns. Could  their field be narrowed to be more unidirectional?  Is there research to support the db level used,  which seems much louder than in the late days of steam and first and second generation diesel?  Is dash dash dot dash the best way to signal level crossings or is it just a tradition not used in many other countries?

Take your pick

https://www.youtube.com/watch?v=mMkJc3xsYC4

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Posted by charlie hebdo on Thursday, June 13, 2019 12:27 PM

Tangential,  but related is the current practice of locomotive horns. Could  their field be narrowed to be more unidirectional?  Is there research to support the db level used,  which seems much louder than in the late days of steam and first and second generation diesel?  Is dash dash dot dash the best way to signal level crossings or is it just a tradition not used in many other countries?

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Posted by Overmod on Thursday, June 13, 2019 12:06 PM

Deggesty
I am trying to remember what locomotive(s) had a siren.

One of the things tried in the 1930s during the 'first wave' of high-speed operation was sirens on locomotives and 'power cars', likely in part because of the similarity to emergency equipment.  (I'll be cynical and speculate at least part of this would involve an intentional similarity to contemporary police sirens...)

I have never seen a consensus other than that these were unsuccessful and discontinued in a comparatively brief time, similar to upward-facing headlights and rotating spotlight beams.

As mentioned, Union Pacific tried some large sirens (you can easily find pictures of Centennials equipped with them - a large thin-rectangular mouth visible just over the cab).  I believe Don Strack covers some of the experiment.  Again this was not 'proceeded with' after testing.

I have frequently thought that steam-locomotive 'quilling' gives many of the advantages of 'pitch' or timbre changing as a means of reinforcing attention.  There have been occasional efforts to duplicate the effect (or the general physics) including unless I'm mistaken on the Hancock air-whistle style (which it seems to me could relatively easily be fitted with a driving coil for adding electronically-amplified signals or e-bell).  It is my understanding that you don't get much if any good effect by modulating the air pressure to diaphragms of a normal type of chime horn, but it does seem possible to vary the relative loudness of bells, within some range, since I believe many modern horns offer 'loudness control' by regulating the admitted air pressure and what works for the horn as a whole would work on individual bells.

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Posted by rdamon on Thursday, June 13, 2019 11:02 AM

Police/Fire/EMS have multi-colored lights and high/low pitched sirens.

Perhaps a elecronic bell could serve more functions.

The electric carts at ATL airport recently installed a high mounted blue LED light that lights up the path infront of people they are approching from behind.

 

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Posted by BaltACD on Thursday, June 13, 2019 10:47 AM

Overmod
 
Euclid
So the point would be to make a horn signal that could be differentiated from that of another train being sounded at the same time. 

This brings up another difficulty that all of us have probably experienced at one time or another - the analogue of phase-coherent multipath interference.

Many's the time that I distinctly hear a horn coming from the direction of a large properly-aligned wall, or hear it much more clearly from the 'false' direction than from where the train actually is.  At Ivy City the conductors had a long train of sound-reflective cars to their left, and any 'directional' characteristic of trains physically in front of or behind them might easily have been confused by reflection from that -- let alone any other potential things in the local environment.

I'm not sure anything but an extremely directional horn that could be steered right onto a 'subject' would cut through this reliably.  When I was much younger, I in fact advocated just such a thing (with the addition of a microphone that could be used to yell at kids wearing then-new Walkman headphones ... dates the era, doesn't it?) complete with some kind of designator that would allow easy and quick steering of the speaker horn onto the 'target' (also dates the era that this was a relatively new approach.)  Problem is that such a thing would become just like the SP experiments in warning lights: perhaps few lives actually saved, but a lot of FRA compliance considerations and a guarantee of strict scrutiny should anyone actually be hurt or killed by a locomotive with the system installed.

Not to mention that the Ivy City area where this happened is a man made canyon of buildings with the railroads and highways in the valley in between.

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Posted by Deggesty on Thursday, June 13, 2019 10:46 AM

Change in pitch to catch attention? How about a siren, which does have changes? I am trying to remember what locomotive(s) had a siren.

Johnny

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Posted by Overmod on Thursday, June 13, 2019 10:10 AM

Euclid
So the point would be to make a horn signal that could be differentiated from that of another train being sounded at the same time.

This brings up another difficulty that all of us have probably experienced at one time or another - the analogue of phase-coherent multipath interference.

Many's the time that I distinctly hear a horn coming from the direction of a large properly-aligned wall, or hear it much more clearly from the 'false' direction than from where the train actually is.  At Ivy City the conductors had a long train of sound-reflective cars to their left, and any 'directional' characteristic of trains physically in front of or behind them might easily have been confused by reflection from that -- let alone any other potential things in the local environment.

I'm not sure anything but an extremely directional horn that could be steered right onto a 'subject' would cut through this reliably.  When I was much younger, I in fact advocated just such a thing (with the addition of a microphone that could be used to yell at kids wearing then-new Walkman headphones ... dates the era, doesn't it?) complete with some kind of designator that would allow easy and quick steering of the speaker horn onto the 'target' (also dates the era that this was a relatively new approach.)  Problem is that such a thing would become just like the SP experiments in warning lights: perhaps few lives actually saved, but a lot of FRA compliance considerations and a guarantee of strict scrutiny should anyone actually be hurt or killed by a locomotive with the system installed.

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Posted by Overmod on Thursday, June 13, 2019 10:02 AM

charlie hebdo
Yes. We are programmed to notice sensory input changes more than constants. Also, strobe flashing can be disorienting and in some people (not only those diagnosed with a seizure disorder) could precipitate a seizure.

There was something else, amusing at the time but I think of some relevance here, that came out of the R10 research -- it had to do with the standard ASCII character rendering codes on IBM terminals of the ancient period around the time many nuclear power plant instrumentation suites were being built with them.  (Those familiar with 'tubes' will recognize this in better context).

IBM had a 'blink' attribute, which by intention worked with bright highlighting to 'convey a need for attention'.  The problem I had with this was that it was only modal 'on-off' blinking, and the transition from full off to full bright was distracting when you actually had first to read the text critically and then think about how to respond to it.

We did very brief testing to confirm that the rather obvious solution -- keeping normal-density display 'on' during the bright 'blink off' interval -- worked better.  (Dimming text cyclically from normal also worked nicely).  Out of this, of course, it's possible to develop fancy cycling of brightness and color, etc. etc. etc. to convey different levels of default or coded meaning.

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Posted by Euclid on Thursday, June 13, 2019 9:57 AM

But remember, in this Ivy City accident the problem was not a failure to hear or understand the horn signal.  It was that the victims mistakenly perceived two train horn signals as one signal. 

So the point would be to make a horn signal that could be differentiated from that of another train being sounded at the same time.    

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Posted by Overmod on Thursday, June 13, 2019 9:46 AM

charlie hebdo
Someone like Dave Klepper, a highly trained acoustic engineer, would likely know best, but changes in pitch would possibly also be more noticeable?

Speaking from a different perspective, I believe there are a number of studies dating well back before WWII that establish changes in pitch as being valuable in emergency alerts -- at least one of them (I regret I've forgotten the citations) being a basis for my understanding that monotone pitches -- even in attractive-sounding or, as KCS and later EMD thought effective, dissonant chords) rapidly become processed as part of ambient noise.  Mr. Klepper will have links to at least some of this material.

Something else Mr. Klepper can certainly tell us with distinctive competence is the best notes to choose, and the best patterns of tonality to consider, to get the most distinctive signal that cuts through ambient noise even at long range.

Something that immediately jumps out at me is the possibility of modulating a block to some of the bells in a chime horn like a K5LA, perhaps with individual solenoid control easily 'retrofitted' to existing horns.  This would allow both the perceived chord and overall timbre to be varied, in patterns that could be more complex than just a 'hee-haw'.

Someone who is familiar with the Union Pacific experiments with Federal Signal-type sirens on locomotives can tell whether they tried modulating the things in some of the ways ambulances/police vehicles do their electronic sirens.  I should point out in passing that I think it's important to keep railroad alert signals DISTINCTLY different from any possible confusion with other types of alert, including weather horns as well as typical first-response sounds, so just putting a good loud PA with an OTS si-reen chip in it on a locomotive is not the right answer.

At least one of our resident Canadians probably knows how they got a locomotive chime horn to blow the first notes of 'O Canada' -- that might be a workable solution.

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Posted by Euclid on Thursday, June 13, 2019 9:45 AM

Overmod
Some nitwit had pushed onto a crossing (we never saw her) and I only noticed the continuous horn-blowing of the approaching train after a few seconds...

Interesting.  So there again is a case of using continuous horn blast as opposed to the correct signal of a succession of short blasts. 

A continous horn blast strikes me as an expression of extreme impatience with the driver.  The industry carries a lot of frustration for crossing violators, and the continous blast seems to be an expression of that frustration by meaning to say "Don't you get it, idiot?"  It almost seems like a form of vengeance rather than warning.

 

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