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switch disaster and afterwards

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Posted by jeffhergert on Saturday, September 19, 2009 1:26 PM

edblysard

 

From the GCOR.

8.8 is intended to make sure that the switch, once thrown, is secure in the thrown position, and the trainman would have a harder time unlocking and throwing the switch under a moving car or train.

8.4 is intended to force the trainman to the opposite side of the track from the switch, and with a train in-between him and the switch, prevent him from throwing the switch under the moving train...this is also part of the inspection process of passing train, the trainman is required by rule to give the passing train a roll by inspection.

 

 

 

8.8 Switches Equipped with Locks, Hooks, or Latches

When not in use, switches must be locked, hooked, or latched if so equipped. Before making movements in either direction over these switches, make sure the switch is latched or secured by placing the lock or hook in the hasp. However, when making train movements in facing point direction, lock the switches equipped with a lock.

Replace any missing or defective switch locks. If they cannot be replaced, report the condition at once to the train dispatcher, yardmaster, or supervisor in charge, and spike the switch if possible.

8.4 Lining Main Track Switch

When an employee lines the switch to let a train enter or leave the main track, the employee must then go to the opposite side of the main track and not return to the switch stand until movement is complete. If unable to go to the opposite side of the track, the employee must stand at least 20 feet from the switch stand.

GCOR 8.7 Clear of Main track Switch also pertains.  At a meeting point when the train is in the siding, crewmembers must stay 150 ft from the main track switch.  There is an exception that in non-signalled territory that if the train being met isn't closely approaching a crewmember may go and examine the switch points to make sure they fit and are properly lined.

It also has an opposite side or 20 foot provision while the other train is passing over the switch.

I agree 100% with Ed.  You only hear about when things go wrong, never the vast majority of times when things go right.

Jeff 

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Posted by erikem on Saturday, September 19, 2009 1:40 PM

Railway Man
As an aside to add to MC's comments on GPS:

GPS is a method of approximating a train location to a physical track location.  It's an input device, just like a track circuit, a track transponder tag, or an axle odometer that counts off distance.  Its good points is that it is cheap and available worldwide (most of the time).  Its bad point is that its accuracy is fuzzy and that makes it vastly less valuable than most people imagine in a rail operating environment where inches matter and the operating technology is based on maintaining but not intruding into small distance tolerances between two or more moving trains. 

 

It's a bit disconcerting how many intelligent and some very intelligent people fail to grasp the accuracy requirements for train control. Contrast this with aviation where a positional accuracy of a hundred feet can be an immense help in preventing mid-air collisions [edit: note can be as opposed to is]. While surveyor grade differential GPS can determine position to within an inch or so, the processing to achieve that accuracy is not compatible with real-time use.

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Posted by MP173 on Saturday, September 19, 2009 3:49 PM

A few months ago, RWM pointed us to an article (author's name forgotten) which resulted in a mid-air collision over the rain forest in South America (Brazil perhaps).  The tracking and navigational ability of the auto pilot systems was very accurate.

In that accident, as in many such events, there are a number of events or mistakes which cascade to the final catastrophy.

"Negetive" momentum (for lack of a better term) has an enormous ability to spiral out of control, when conditions are ripe.

The original post discusses the human aspect of this accident.  How does one handle that type of situation? 

The science of the mind is very fascinating and equally complex.

ed

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Posted by Anonymous on Saturday, September 19, 2009 4:10 PM

MP173

"Negetive" momentum (for lack of a better term) has an enormous ability to spiral out of control, when conditions are ripe.

The original post discusses the human aspect of this accident.  How does one handle that type of situation? 

You make a rule requiring people to stay away from switches under circumstances where impulse-throwing-of-a-switch would be catastrophic.

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Posted by Anonymous on Saturday, September 19, 2009 9:33 PM

locoi1sa

 This is the official ICC report on the accident.

http://ntl1.specialcollection.net/scripts/ws.dll?browse&rn=3649%22

   Pete

Pete,

 

Thanks for posting that link to the wreck report.  In reading it, I am surprised at the points it raises that seem to conflict with and/or raise questions about the story as told in Trains Sept. 1998 issue.

 

For instance, in reading that story, I had concluded that the fireman thought that the engineer was telling him that the switch was mistakenly lined into the siding, and the engineer wanted him to line it for the mainline.  However, the wreck report says that the fireman said that he thought the engineer wanted him to line it into the siding, so that is what he did.  There is a tremendous difference. 

 

If the fireman believed that the engineer was telling him to line the switch into the siding, I cannot understand how the fireman could have believed that because lining it for the siding would obviously not make any sense.  This explanation is in total conflict with the explanation that the fireman panicked, not knowing whether or not the switch was correctly lined for the main. 

 

This information contained in the wreck report strikes me as being incredibly odd.  Apparently this is only the testimony of the fireman since it is not specifically corroborated by the official conclusion of cause in the wreck report, although that official conclusion would allow the fireman’s explanation for his actions. 

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Posted by Paul_D_North_Jr on Sunday, September 20, 2009 4:25 AM

Railway Man

TH&B
The Santa Fe accident was caused by somebody throwing the switch right in front of the train.  Does PTC require electric switch locks ?  If not, the GPS thing [PDN edit: PTC, to get rid of the GPS side issue] does nothing against somebody throwing the switch last minute, after the train is cleared by PTC.

 

The FRA preliminary rules for PTC will still require electric switch locks for hand-throw switches in signaled territory if the maximum authorized speed is greater than 20 mph main track or 30 mph on a controlled siding, or a leaving signal in lieu of the electric switch lock.  Otherwise switch locks and leaving signals will not be required.  The electric switch lock is a device to prevent a hand-throw switch from being opened if there is an occupancy in the circuit, until time has run.  It has nothing to do with a power switch. [emphasis added - PDN] 

[snips]

RWM

Will or do the FRA's proposed PTC rules require electric switch locks for hand-throw switches in what we today refer to as non-signalled or 'dark' territory ?  Or will the PTC installation be considered as effectively converting such territory to signalled territory anyhow ?

In my previous post, I was not addressing the case of a power-operated switch that had been disconnected and put into hand-operated mode, nor other kinds of 'work-arounds' or bypasses of the set-up of the electric switch lock - just the normal capability of the equipment - which seems to me to be yet another special situation.  People can do lots of odd things, I suppose, and the designers and systems can anticipate and guard against many or even most of them - but not absolutely all.

- Paul North.

"This Fascinating Railroad Business" (title of 1943 book by Robert Selph Henry of the AAR)
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Posted by locoi1sa on Sunday, September 20, 2009 6:45 AM

  The thing I found strange about the report is there is no mention of hours of duty time for any of the crew. Could it have been fatigue of the crew? Could it have been that the fireman was new to this particular line and unfamiliar with his surroundings? Most other ICC investigation reports have on duty times and experience on the division of the accident. Some reports even tell what the train crews were doing before their tour of duty. What strikes me as odd about the accident is the unlocking of the switch before the oncoming train. Did he do this to save a minute of time after the meet? Why touch the switch before the meet? The points were lined for the main when he walked up to the switch stand. He should have seen that. Is there a rule stating that switch locks should be unlocked before a meet? If there is. Why?

       Pete

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Posted by Anonymous on Sunday, September 20, 2009 2:46 PM

locoi1sa

  The thing I found strange about the report is there is no mention of hours of duty time for any of the crew. Could it have been fatigue of the crew? Could it have been that the fireman was new to this particular line and unfamiliar with his surroundings? Most other ICC investigation reports have on duty times and experience on the division of the accident. Some reports even tell what the train crews were doing before their tour of duty. What strikes me as odd about the accident is the unlocking of the switch before the oncoming train. Did he do this to save a minute of time after the meet? Why touch the switch before the meet? The points were lined for the main when he walked up to the switch stand. He should have seen that. Is there a rule stating that switch locks should be unlocked before a meet? If there is. Why?

       Pete

 

The wreck report states the rules, which say that a switch must not be unlocked before a meet.  In the case of this Robinson wreck, there were two locks, one for the switch, and one for the treadle, which was a foot operated mechanical latch for the switch stand mechanism.  To throw the switch, required unlocking both the treadle and the switch stand, and then stepping on the treadle, and then throwing the switch. 

 

I assume that the fireman unlocked the treadle to save that little bit of time while he had time to kill ahead of the meet.  Once the opposing train had passed, everything the fireman had to do would take time that would delay his train.  I think he felt that he was making efficient use of time by unlocking the treadle ahead of the meet.  However, it would have been a rules violation. 

 

The rules also require trainmen to keep a specified minimum distance from the switch as a way to help prevent an impulse throwing of the switch.  While fatigue could contribute to impulse throwing of a switch, the act has been found to have its own unique psychological cause, which appears to have common potential among different people.  It is not just an outcome of the “anybody can do anything” principle.  It is a specific type of confusion and panic that is associated with railroad switches and their potential consequences of being lined wrong.

 

The fireman violated the rule about standing next to the switch and also the rule about unlocking it (assuming that that rule also applied to the treadle).  Apparently he saw no practical reason to abide by these rules, if he was aware of them.  But the practical reason snuck up on him in the form of raising doubt in the mind of the observing engineer.  The engineer would have expected no manipulation of the switch stand before the meet, and yet he saw the fireman make a concerted effort to do something with the switch.  The doubt this raised with the engineer was then projected as feedback to the fireman, thus raising doubt in his mind about the switch being lined right as the meeting train bore down on him.

 

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Posted by Anonymous on Monday, September 21, 2009 12:03 PM

I have a question: 

 

Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

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Posted by tree68 on Monday, September 21, 2009 1:03 PM

Our mainline switch movements are reported on the air by the crew member throwing the switch, to be repeated by the engineer.  If it's an over-and-back movement, with the switch to be restored to its starting position and me in a position to watch it, I may not lock it, but I will leave the lock in the hasp, more to ensure that the handle won't pop up and allow the switch to move under the locomotive/cars than anything else.

The 20'/across the tracks rule notwithstanding, we often move to where the engineer can see us, which helps ensure that another set of eyes is making sure we don't second guess ourselves.  Another good reason for using hand signals....

I never walk completely away from an unlocked switch.  Don't want my keys to wander.

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Posted by Paul_D_North_Jr on Monday, September 21, 2009 1:03 PM

Bucyrus
[snip; emphasis in original]

The rules also require trainmen to keep a specified minimum distance from the switch as a way to help prevent an impulse throwing of the switch.  While fatigue could contribute to impulse throwing of a switch, the act has been found to have its own unique psychological cause, which appears to have common potential among different people.  It is not just an outcome of the “anybody can do anything” principle.  It is a specific type of confusion and panic that is associated with railroad switches and their potential consequences of being lined wrong. 

Bucyrus - Thanks for your efforts in reviewing the ICC report and posting your summary, analysis, and comments on same.  What you say about the inconsistencies makes a lot of sense to me.

One follow-up question regarding your "unique psychological cause" statement above:  Is that assertion one that you saw or read someplace, or your own conclusion from reviewing the article in Trains and the ICC report ?  I'm not challenging it, either way - I'm just curious - and a little surprised  - that this 'syndrome' might have gathered enough 'official' attention to result in a 'finding' to that effect, and if so, I'm curious as to the who/ what/ were/ when aspects of it - that's all.

Thanks again.

- Paul North.

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Posted by Anonymous on Monday, September 21, 2009 3:25 PM

Paul_D_North_Jr

One follow-up question regarding your "unique psychological cause" statement above:  Is that assertion one that you saw or read someplace, or your own conclusion from reviewing the article in Trains and the ICC report ?  I'm not challenging it, either way - I'm just curious - and a little surprised  - that this 'syndrome' might have gathered enough 'official' attention to result in a 'finding' to that effect, and if so, I'm curious as to the who/ what/ were/ when aspects of it - that's all.

Thanks again.

- Paul North.

Paul, 

 

With regard to this syndrome of last second panic in believing that a properly lined switch is not properly lined: 

 

I come to this conclusion that it is a syndrome largely by my own analysis, although I have heard of accounts that seem to corroborate the problem.  It also makes sense logically, because I know that if one were the last to use a switch, the compulsion to second guess oneself about the position of that switch rises as the consequences of that switch being wrong rise. 

 

I read a story in Railroad Magazine that goes into some detail about this potential pitfall, and how to avoid it.  I still have that issue, so I might dig it up to check it.  As further evidence of the syndrome, the Robinson wreck plays it out perfectly.  In other words, whether the problem of switch panic is a syndrome or not, it actually happened at Robinson.  It snuck up on the fireman responsible for the Robinson wreck.  It seems like it could sneak up on anybody, as was the topic of the Railroad Magazine story. 

 

I have also read of one or two incidents where this type of switch panic caused wrecks, and I was given a verbal account of an incident on the Milwaukee Road where a trainman panicked and threw a switch wrong in the face of a passenger train, and then realized his mistake and threw it right again just in time.  He threw it wrong in the first place, thinking it was wrong and he was throwing it right.

 

As further evidence of switch panic being a syndrome, there is the rule prohibiting trainmen from standing near the switch during a mainline meet where the consequences of switch panic second guessing would be at their highest.  Somewhere, I have seen confirmation that this is the reason for the rule.  Perhaps it was on this forum not too long ago when we were discussing something related to this. 

 

I have known about the rule for many years, but up until this recent revelation about the purpose, I had been mistaken about what the purpose for the rule is.  I had thought that the purpose of the rule was to prevent trainmen from being injured or killed if dragging equipment happened to snag the switch and rip out the switch stand, thus injuring or killing a trainman who was standing near it.  

 

Fatigue and/or miscalculation is another type of cause for switch throwing mishaps.  This is a very common cause for this type of accident in yard switching where it is common to mistakenly throw switches under cars or locomotives.  It seems like a natural peril when one is throwing a lot of switches in a given amount of time, and when one gets accustomed to throwing switches as soon as the wheels clear the points. 

 

But the kind of switch mistake that I am referring to has an entirely different cause than fatigue and/or miscalculation.  What I am talking about is the panic throwing of a switch where the cause is based on a loss of confidence.  It is not the same thing as miscalculation such as occurs when throwing a switch under an engine or car in the yard. 

 

Other than my own reasoning and antidotal evidence as described above, it would indeed be very interesting to discover some official reference that details this loss of confidence switch panic as a syndrome.  I would not be surprised if such a study does exist, but I have not seen it if it does. 

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Posted by wabash1 on Monday, September 21, 2009 4:21 PM

Bucyrus
I have a question: 
 
Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

Other than talk about the rule violation that was just commited there is nothing you can do . 

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Posted by Anonymous on Monday, September 21, 2009 4:43 PM

wabash1

Bucyrus
I have a question: 
 
Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

Other than talk about the rule violation that was just commited there is nothing you can do . 

I know an engineer could not stop before reaching the switch or the opposing train, but would you try to slow down?  I am just wondering how an engineer would react to having the headlight of the train in the siding come on.  It could just be a harmless mistake for some reason, or it could mean something serious. 

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Posted by Kootenay Central on Monday, September 21, 2009 5:23 PM

.

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Posted by wabash1 on Monday, September 21, 2009 6:30 PM

Bucyrus

wabash1

Bucyrus
I have a question: 
 
Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

Other than talk about the rule violation that was just commited there is nothing you can do . 

I know an engineer could not stop before reaching the switch or the opposing train, but would you try to slow down?  I am just wondering how an engineer would react to having the headlight of the train in the siding come on.  It could just be a harmless mistake for some reason, or it could mean something serious. 

why would you atempt to slow down at 1000 ft you would not acomplish much anyways and also there is no reason to slow down. the only thing it means is that the idiot in the other engine made a mistake.... if you want to call it that and made a rule violation by turning on the headlight. at night at train meets the headlights will be turned off, unless your about to go across a crossing at grade.then the engine moving will keep his on bright.

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Posted by Anonymous on Monday, September 21, 2009 7:03 PM

wabash1

Bucyrus

wabash1

Bucyrus
I have a question: 
 
Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

Other than talk about the rule violation that was just commited there is nothing you can do . 

I know an engineer could not stop before reaching the switch or the opposing train, but would you try to slow down?  I am just wondering how an engineer would react to having the headlight of the train in the siding come on.  It could just be a harmless mistake for some reason, or it could mean something serious. 

why would you atempt to slow down at 1000 ft you would not acomplish much anyways and also there is no reason to slow down. the only thing it means is that the idiot in the other engine made a mistake.... if you want to call it that and made a rule violation by turning on the headlight. at night at train meets the headlights will be turned off, unless your about to go across a crossing at grade.then the engine moving will keep his on bright.

Thanks Wabash.  I was just wondering how concerned an engineer would be about seeing the headlight on the train in the siding come on.  It might mean that the guy on the other engine made a mistake, but might it also mean that the standing engineer was trying to tell the approaching engineer that something was wrong such as not being in the clear, switch not lined, etc?  I suppose he would have lit a fusee if that were the case though.  I wonder if these ATSF trains had radios in 1956 that would have allowed the engineers to talk to each other. 

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Posted by jeffhergert on Monday, September 21, 2009 8:24 PM

Bucyrus
I have a question: 
 
Suppose you are an engineer running a passenger train at night down the mainline at 79 mph, and approaching a meet with an opposing passenger train, which is waiting in a siding with its headlight turned off.  Now suppose that train in the siding turns on its headlight when you are say 1000 feet away.  What, if anything, do you do?

At one time, with variations depending on rule book and type of territory (ABS,CTC,dark etc), a displayed headlight meant the train in the siding hadn't cleared the main track.

One book I have says the headlight will be displayed on bright while the train is moving into the siding.  Once the train is clear of the main track, it will be dimmed while moving on the siding and extinguished once stopped clear of the main track. 

Jeff

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Posted by wabash1 on Tuesday, September 22, 2009 6:17 PM

turning on the headlight means nothing, if something was wrong we have bad signals and would have already been talking to the opposing train, Besides on the track authority it says that we must meet train so/so before you can leave unless he cleared his warrent . if that was done then he already in the clear. things back then was differant but now a days its real simple. you dont go until the other train reports clear.

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Posted by Anonymous on Tuesday, September 22, 2009 7:16 PM

Actually, I overlooked something when I asked the question about what an engineer would do if approaching a meet and the train in the clear turned its headlight on.  The reason for the question was in relation to the 1956 ATSF wreck at Robinson, NM, so I should have asked what an engineer’s response would be when running on the ATSF at that location, and in that timeframe. 

 

I have been trying to analyze the details of how the engineer tried to communicate with the fireman, what he was trying to say, and how it confused the fireman to make the fatal error.  I conclude that there are several different possible variations on how these events came together and what each man believed about what the other was doing.     

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Posted by wabash1 on Wednesday, September 23, 2009 7:30 AM

why try and guess what the engineer did or did not do. It could have been that the engineer did not trust the guy he was working with, In that he turn on the light to see if he went up and did anything to the switch. and seeing that the switch was fine turned the light out. then the fireman for what ever reason threw the switch, I would be more likely to ask why was the fireman on the ground he should be on the engine. there is usually a  5 man crew on board at that time frame one of the switchmen should have been on the ground. When I'm working with someone i dont trust I turn the headlights on and off checking what he is doing.

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Posted by BarReb75 on Friday, September 15, 2017 11:07 AM

Robinson was actually not near Onava.  It was the first siding south of Springer, around MP 706-708, which is around MP 759.

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Posted by BarReb75 on Friday, September 15, 2017 4:05 PM

The switches at Robinson, as was the case at all ends of sidings on the ABS territories, was indeed a high-star stand, but was equipped with a "Mechanical Switchman" spring switch buffer, which allowed a train leaving the siding to just buffer its way out without having to hand throw the switch to line out and then line it back for the Main after the rear end was on the Main.  Spring switches were not easy to throw because of the hydraulic buffer and the big spring inside, and it WAS necessary to keep the switch plates graphited and all connections tightened.

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Posted by BarReb75 on Friday, September 15, 2017 4:17 PM

Electric locks WILL indeed prevent the hand throwing of a switch in front of an approaching train.  The signal circuits will keep the electric lock relay on the lock unit (SL-21A, 9B, etc) from energizing and releasing the lock feature IF the signal circuits are not in their NORMAL condition... "normal condition" meaning no track occupancies, no Signals Cleared into the block either direction at CTC control points, etc.  Santa Fe and BNSF only used/use electric locks on CTC territories and around certain Interlockings everywhere I worked during my 42+ year Signal career.  At any rate, unless the locking circuitry is defeated by vandalism, other damage, or misarranged circuitry, the switch can not be thrown until the full time has run (I've seen as long as 15 minutes), with the exception that if all circuits are clear of trains and no controlled signal is lined over that route, most switches do have a quick unlock circuitry that does not require the full time to run.

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Posted by BarReb75 on Friday, September 15, 2017 4:22 PM

That should have read "Onava is around MP 759".

 

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Posted by diningcar on Friday, September 15, 2017 4:58 PM

I was working (engineering dept) in this area at the time of the Robinson siding 'head on'.  Robinson no longer exists but soon after 'spring switches' were installed there, and at several other sidings on the Northern Passenger line to eliminate the need to have someone throw a switch to exit a siding.   

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Posted by Paul_D_North_Jr on Saturday, September 16, 2017 4:59 PM

NKP guy
 May I venture another angle on this matter?

 The discussion so far has been interesting and perhaps revealing.  To me, the really interesting part of this story is not what might have prevented the accident, but how a person goes on, for years, in a small community where everyone knows the story of what happened.  What kind of a person, and a town, can successfully deal with it all?  That's the beauty and wonder of this story, as far as I'm concerned.

Perhaps another point would be the legal ramifications of such an accident today.  Would it even be possible for this unfortunate man to avoid jail?  How many lawyers, and for how many years, would this case involve if it were to happen today? And why didn't it happen then?  What would be the likely outcome today?

Again, thanks to everyone for his contributions to this thread. 

Not quite the same, but nevertheless consider these wrecks which involved loss of life and the engineer survived:

- Ricky Gates, the engineer of the ConRail engines that ran through a switch and were then run into by the Amtrak Colonial at the Gunpowder River interlocking;

- Brandon Bostian, the engineer of Amtrak 188 which derailed from excessive speed on a sharp curve at Frankford Jct. couple years ago (current on-going thread here about that).

- PDN. 

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Posted by Falcon48 on Saturday, September 16, 2017 10:50 PM

carnej1
 
ndbprr

A variation of this occured in Harvey, Illinois on the IC about 30 years ago.  A southbound freight was waiting to leave Woodcrest and was waiting for a northbound Amtrak train to pass.  A rookie on the freight crew was told to throw the tunrouts after the passenger passed and mistook a northbound commuter for the Amtrak train and threw the crossover right in front of it.  The lead engine of the freight was cleaned off at the frame.  The crew did not survive.  There were no major injuries to the Amtrak crew or passengers as I remember.

 

 

 

Interesting...wasn't that the same stretch of line that saw the terrible IC commuter wreck in the early Seventies where an older steel E.M.U train rear- ended a new aluminum double decker trainset with many injuries/fatalities? That accident also involved a misaligned switch, although  IINM it was an automated switch and the accident resulted from a dispatching error....

 

  If you are referring to the 23rd Street colision, it had nothing to do with a misaligned switch.  The underlying causes were (i) the leading train overshot a station and reversed directions while being approached by a following train (2) the motorman of the following train saw a signal far ahead of his train change to a more permissve indication and increased speed before passing the signal, apparently assuming that the signal had changed because the leading train was far ahead of it.  In reality, the signal had changed because the leading train had backed out of the block towards the following train, 

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