I have read and re-read this NTSB report three times. The signal system was suspended for cut-over to PTC on that part of the CSX. The conductor and engineer failed to restore the silica spur switch to normal (Main Track to Main Track) position and the AMTRAK train headed into the spur and collided with a standing CSX train. The AMTRAK conductor (on the locomotive) and the AMTRAK engineer were killed.
Both CSX crew members were fired for their part of the this terrible accident.
Regarding liability, could the family members of the AMTRAK employees killed sue the CSX for damages? What about the injured AMTRAK passengers?
The NTSB blamed the CSX for their part of this tragedy.
I am interested in what Balt has to say about this. I did not find another blogs about this accident.
Ed Burns
Retired Clerk from Northtown-Minneapolis.
Total man failure incident by the switcher crew; no excuses for their failures.
I have no idea how or how much the liability issues will be adjudicated; I doubt that it will be in CSX's favor. In the US anybody can sue anybody else for any reason they can think of - whether it will ever make it to Court is another matter entirely.
Never too old to have a happy childhood!
No doubt the individuals will be sued: that is a drop in the bucket.
Under deep pockets, CSX will be sued, and they'll be paying plenty.
I suspect there will be diligent efforts to assign some percent of the blame, no matter how slight, on Amtrak, so further deep-pockets can go after the $225 million capped insurance available there. But I suspect CSX, whether wholly or partially self-insured in these matters, will be paying for most of the awards or settlements, and most of the probably fabulously lavish fees and costs. Not very much legal cleverness or time are going to be required to establish liability in civil actions, which is where the real 'action' as it were is going to be. Look for criminal penalties on the workers, and perhaps on the railroad (if there are some undocumented foibles in their government-related paperwork for strict scrutiny to find and for politically-astute lawyers to find, publicize, and exploit in not-necessarily-related ways to establish a perception of relevant guilt) but those aren't really meaningful in any justice-related or safety-enhancing sense, and certainly are a drop in the bucket compared to the civil settlements to come.
BaltACDTotal man failure incident by the switcher crew; no excuses for their failures.
Yes there is. Poor vetting, poor training, poor supervision.
243129 BaltACD Total man failure incident by the switcher crew; no excuses for their failures. Yes there is. Poor vetting, poor training, poor supervision.
BaltACD Total man failure incident by the switcher crew; no excuses for their failures.
Those may be reasons - they are not excuses.
Balt:
I believe you said that EHH got rid of all the local trainmasters and RFE. If that is true, who is supervising the train and engine crews?
NP EddieBalt: I believe you said that EHH got rid of all the local trainmasters and RFE. If that is true, who is supervising the train and engine crews?
To my knowledge EHH 'surplused' the RFE's. The Trainmaster's remained, and I believe were expected to perform 'double duty' - despite many (most) of them never having been qualified Engineers.
BaltACD 243129 BaltACD Total man failure incident by the switcher crew; no excuses for their failures. Yes there is. Poor vetting, poor training, poor supervision. Those may be reasons - they are not excuses.
Those are reasons. A properly vetted prospective employee would have possessed the common sense to double check their actions when questioned. A properly trained employee would have followed the designated procedure for that action. Supervision should have been able to detect that the employee was deficient in railroad operations procedures.
And supervision should have been doubled for the de-activation of a reliable safety system in advance of its replacement by PTC.
daveklepperAnd supervision should have been doubled for the de-activation of a reliable safety system in advance of its replacement by PTC.
Where do you place your doubled supervision? Every Main Line train? Every road switcher operating? How many supervisors is doubled supervision?
This happened on the EHH version of CSX, wherein he reduced supervision in multiple categories.
Fortunately, I never worked on the EHH version of CSX.
You are more of an expert than I am as to how to most effectively increase supervision. You are noting that EHH effectively reduced supervision, and I am simply agreeing with you that this reduction may, not absolutely certain, but may have contributed to the accident.
The reality of ANY situation - you don't have all the Supervision you may think you need. Second you have to expect employees to comply with the most basic of rules.
BaltACDSecond you have to expect employees to comply with the most basic of rules.
Poor training.
243129 BaltACD Second you have to expect employees to comply with the most basic of rules. Poor training.
BaltACD Second you have to expect employees to comply with the most basic of rules.
I guess you were the trainer. I wasn't. In the world of human endeavor - even the best trained and exhaustively drilled still make mistakes. Something about the human condition not being 100% perfect 100% of the time. Failures in the railroad world have a high cost - in human lives and property damage. Property damage being secondary.
In the end CSX will pay little, since if folks recall, Amtrak under their contracts with the carriers assumes all financial liability and indemnifies the carriers for their expenses no matter the cause. I dont recall hearing that this has changed in the past few years.
Exactly, Balt, and that is exactly why signal systems improved safety. If the signal system had not been deactivated, the Amtrak engineer would have known that the switch was not set correctly. And if it were not for EHH, CSX would have not permitted such a long time gap between removal of block signal protection before PTC implementation, or less likely, would have imposed special conditions, possibly a speed reduction for temporary dark territory or just on approaching switches.
daveklepperExactly, Balt, and that is exactly why signal systems improved safety. If the signal system had not been deactivated, the Amtrak engineer would have known that the switch was not set correctly. And if it were not for EHH, CSX would have not permitted such a long time gap between removal of block signal protection before PTC implementation, or less likely, would have imposed special conditions, possibly a speed reduction for temporary dark territory or just on approaching switches.
Before I retired on my territory, we would have roughly one or two Signal Suspensions per month as Control Points were upgraded for the ability to support PTC.
Months before, signal construction gangs would perform the work of installing new foundations and other items necessary to install PTC supportable equipment - signal masts, signals, electronic cabinets etc. The suspensions would normally cover three adjoining Control Points at a time and be undertaken mostly on Friday's into the weekend. The middle of the three Control Points would be the one that was having its equipment upgraded. Most were completed within a 36 hour span of time from start to finish - which in reality would be two twelve hour days for the Signal Dept. employees as they are covered by Hours of Service regulations. If problems were encountered, the suspension could be in effect for a longer period of time - never exceeding 72 hours in my observations.
Announcement of the Signal Suspension would go out a 'Superintendents Bulletin' in the week before the scheduled date of the suspension. Starting about 16 hours prior to the effective date and time of the suspension, a point of contact (specified in the bulletin) is opened that ALL Crews going on duty that would be operating through or in the area defined by the suspension were required to contact the individual manning the contact point to discuss the specific requirements of what crews had to do in operating through, or in, the defined limits of the suspension. The contact point would be manned by either a local operating official for the area or a senior T&E craft employee that has demonstrated both the ability to communicate as well as fully understanding the rules in play and how those rules with apply to those crews operating within the limits of the suspension.
Once the suspension commences, the Train Dispatchers involved will be closely monitored by the Chief Dispatcher in the office on the issuance and release of the Track Warrant Authorities. The Signal Department would hire a 'Communicator' (normally a retired Chief Dispatcher, hired as a consultant) to act as intermediary to communicate the conditions signals requires to test various aspects of the new installation that the Train Dispatcher must set up by routing trains in specific ways through the limits of the suspension.
The Signal Suspension Bulletin would state that the signals at the first and third control points mentioned, while operating, would ONLY be conveying 'switch position' not movement authority - movement authority being conveyed by specific Track Warrant authority to the individual train(s). Trains would operate at the FRA speeds required of operation in DARK territory - 59 MPH for passenger, 49 MPH for freight.
When I was working on the Baltimore Division, pre EHH, Signal Suspensions were taken VERY SERIOUSLY by all concerned as it was understood that the field employees were being tasked with operating under a rules system they have had relatively little experience working under.
The Cayce incident happened on the Florence Division during the after EHH period - I have NO IDEA how that division was administrating their Signal Suspensions at the time of the incident.
I agree with Balt. Job perfomance failures cannot always be chalked up to poor training or supervision.
A well-trained person can go for years performing exemplary service, then one day go to work after a bad night's sleep, or a death in the family, or having just learned their wife is having an affair, or whatever. They are distracted, exhausted. All of us have had days on the job where we got through the day on autopilot.
Or, we made mistakes; but they did not yield tragic results. Once I photographed and impatient, stuffy New York state senator ... then had to tell him I had forgotten to put film in the camera. No one died, even though I wanted to.
Anyone can make a mistake. Now, there is no excuse for the negligence of these CSX men. Even though the trainmaster may get pissed, if you are not fit for service you have to mark off.
Then there are people who were once great employees who eventually simply get bored and/or careless. This is not the fault of the person who trained them fifteen years before. This is not the fault of the supervisor who has noted their good performance all through the years. But then one day the carelessness, boredom, and complacency has consequences.
As for the Amtrak liability law, it certainly will be a travesty for Amtrak to have to eat this one, when the blame is 100% on the two CSX employees.
It sounds like NTSB is blaming CSX for operating with excessive risk.
If there is anyone who would be interesting to hear an explanation from, it is the conductor who failed to reline the switch in this collision. Are his interviews available as part of this NTSB accident report?
An interview is needed to provide insight into his state of mind. An interview of the engineer would also be helpful to understand how a single point could have been gotten so wrong when you have the formal switch position verification procedure and the full professional knowledge of how critical that one point was. Although, as I understand, the switch verification procedure had not been used by either the conductor or the engineer for quite some time, and it was only used at Cayce during the signal suspension.
As I recall, the conductor was seemingly unwilling to even consider that he had not relined the switch even with the engineer explaining to the conductor that he never saw the conductor reline it; and would have seen him reline it if he had done so. So prior to the collision, question of the switch position was laid on the table between the conductor and the engineer. It is my understanding that the crew was responsible for agreeing that the switch was properly lined for the passenger train.
Only when time was running out did the engineer’s doubt rise high enough to walk to the switch and check it. And, the conductor did not go with him. So there was a stark disagreement between the engineer and conductor about that position of that switch. Just because of that disagreement existing when the rules require full agreement; at that instant, they should have called the dispatcher and had the dispatcher stop the Amtrak train.
Stopping Amtrak should have taken precedence over checking the switch, because time for checking the switch had run out.
Sure, we all make mistakes. That's just an excuse, much like "s**t happens."
I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
matthewsaggie In the end CSX will pay little, since if folks recall, Amtrak under their contracts with the carriers assumes all financial liability and indemnifies the carriers for their expenses no matter the cause. I dont recall hearing that this has changed in the past few years.
Johnny
charlie hebdo Sure, we all make mistakes. That's just an excuse, much like "s**t happens." I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
Of course. "Less likely." Absolutely. I doubt anyone would disagree.
But such individuals still make mistakes. In this case I know of no facts that point more at the trainers/supervisors than at the offending employees. (It sounds like one employee might be "more guilty" -- if such a concept even exists -- than the other, in real terms. But, job-wise, both are equally guilty, IMO.
Does anyone know of any supervisors/trainers getting fired over this incident? (I'm not contendig that would prove anything, btw.)
Lithonia OperatorIt sounds like one employee might be "more guilty" -- if such a concept even exists -- than the other, in real terms.
I would opine that the employee who failed to restore the switch would hold primary guilt. The engineer would basically be an accessory. By rule, however, both are guilty.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
The NTSB lists four elements of the probable cause, apparently in order of importance. The first listed element of probable cause is the failure of CSX to assess and mitigate the risk of operating through the signal suspension.
From the report:
"Probable Cause
The National Transportation Safety Board determines the probable cause of this collision of trains was the failure of the CSX Transportation Corporation to assess and mitigate the risk associated with operating through a signal suspension, which eliminated system redundancy for detecting a switch in the wrong position.
The CSX Transportation Corporation conductor failed to properly reposition the switch for the main track, which allowed National Railroad Passenger Corporation (Amtrak) train P91 to be routed onto the Silica Storage track where the standing CSX train F777 was located.
Contributing to the accident was the Federal Railroad Administration’s failure to implement effective regulation to mitigate the risk of misaligned switch accidents. Also contributing to the accident was National Railroad Passenger Corporation’s (Amtrak) failure to conduct a risk assessment prior to operating during a signal suspension."
"Less likely" will come into question when the apportionment of percentages of liability in a civil suit is made.
charlie hebdoSure, we all make mistakes. That's just an excuse, much like "s**t happens." I tend to agree with Joe. People who were properly vetted for the needed cognitive set, were trained thoroughly about procedures and are periodically checked on (supervised) are less likely to make mistakes. It's all about probabilities.
Start reading accident reports - all kinds of them - railroad, airline, pipeline and marine accidents.
What you will find over and over again - sometimes even the 'best, most grounded, most rule compliant, most responsible' make mistakes. Yes the undertained, undermotivated, sloppy, lackadaisical and bad employees make most of the mistakes. But mistakes are not the exclusive property of bad employees.
I am not making any assessment as to whether the CSX employees involved in the Cayce incident were either good or bad. They made the mistake - they have to live with the consequences.
BaltACDWhat you will find over and over again - sometimes even the 'best, most grounded, most rule compliant, most responsible' make mistakes.
It seems to me that the Japanese "point and call" technique acknowledges your assertion here. Point and call teaches employees to be aware of the possibility of making mistakes, and uses a technique of consciously recognizing that possibility, and constantly questioning whether a mistake is being made.
Japanese would have probably assigned a switch tender to each switch.
It's been fun. But it isn't much fun anymore. Signing off for now.
The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any
zugmannJapanese would have probably assigned a switch tender to each switch.
On CSX, at least the Baltimore Division, where crossovers were involved at the Control Point that was being updated, Switchtenders would be assigned to operate the crossovers at the Train Dispatcher's direction. Such switchtenders were to eliminate the need for a train to stop, throw their own switches when making a crossover move as well as being required to realign the crossovers to the Normal position after their use.
Crossovers were not involved in the Cayce incident.
Manpower has been a recurring problem in staffing switchtender positions.
Cayce did not need switch tenders. It needed a way to separate the recall of a most recent action from all other previous actions that were identical to the most recent action. If the conductor had never thrown that switch in the past, except for once throwing it to line it for the main line, he would have never fogotten that act. The japanese system recognizes that human vulnerability of mixing up past identical actions. So their point and call is a technique to attach new symbols to those new actions so they are less likely to be confused with earlier identical actions. Point and call forces users to do things without being guided by habbit.
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