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CSX vs. Amtrak 91 at Cayce, SC

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Posted by blue streak 1 on Friday, February 16, 2018 10:28 PM

Does this mean that the CSX crew were on the CSX locos shortly before the collision ?

https://www.ntsb.gov/investigations/AccidentReports/Reports/RSR1801.pdf?utm_source=news&utm_medium=email&utm_content=railroad

 

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Posted by ruderunner on Saturday, February 17, 2018 6:38 AM

to me it sounds like they were on the locomotive moments before and indeed the conductor was on board during impact. ThankflTha no longer in the cab.

This tightens up the time window considerably.

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Posted by Euclid on Saturday, February 17, 2018 7:55 AM

Early in the thread called, Misaligned Track Switches That Cause Wrecks, I suggested that during signal suspension, switches should be approached at “Restricted Speed.”  But I was told no; that cannot be a proper solution because it would not permit meaningful transportation to take place.  I was told that the switch position verification forms were all that is needed.  Then as long as everyone does their job, everything will be okay. 

Now, the NTSB has come to this conclusion:

 

Recommendation

As a result of this report, the National Transportation Safety Board makes the following urgent safety recommendation:

To the Federal Railroad Administration:

Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the locationmust approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (R-18-005) (Urgent) 

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Posted by 243129 on Saturday, February 17, 2018 8:12 AM

Euclid

Early in the thread called, Misaligned Track Switches That Cause Wrecks, I suggested that during signal suspension, switches should be approached at “Restricted Speed.”  But I was told no; that cannot be a proper solution because it would not permit meaningful transportation to take place.  I was told that the switch position verification forms were all that is needed.  Then as long as everyone does their job, everything will be okay. 

Now, the NTSB has come to this conclusion:

 

Recommendation

As a result of this report, the National Transportation Safety Board makes the following urgent safety recommendation:

To the Federal Railroad Administration:

Issue an Emergency Order directing railroads to require that when signal suspensions are in effect and a switch has been reported relined for a main track, the next train or locomotive to pass the locationmust approach the switch location at restricted speed. After the switch position is verified, the train crew must report to the dispatcher that the switch is correctly lined for the main track before trains are permitted to operate at maximum-authorized speed. (R-18-005) (Urgent) 

 

When manual block rules were implemented, approaching all facing point switches at restricted speed was standard operating procedure on the railroads I worked for here in the northeast. I don't understand why this is not a nationwide requirement.

 

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Posted by BigJim on Saturday, February 17, 2018 8:41 AM

blue streak 1
Does this mean that the CSX crew were on the CSX locos shortly before the collision ?

Posted by ruderunner on Saturday, February 17, 2018 7:38 AM

to me it sounds like they were on the locomotive moments before and indeed the conductor was on board during impact. ThankflTha no longer in the cab.

This tightens up the time window considerably.


Not the way that I read it. This is not specifically about the the SC accident. It is worded in a way to bring context to the NTSB recommendation.

Unfortunately, you are confusing the different noted senarios on other RR's and superimposing them into the SC incident.

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Posted by edblysard on Saturday, February 17, 2018 9:02 AM

ruderunner

to me it sounds like they were on the locomotive moments before and indeed the conductor was on board during impact. ThankflTha no longer in the cab.

This tightens up the time window considerably.

 

Sounds like it.

23 17 46 11

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Posted by Overmod on Saturday, February 17, 2018 9:12 AM

243129
When manual block rules were implemented, approaching all facing point switches at restricted speed was standard operating procedure on the railroads I worked for here in the northeast. I don't understand why this is not a nationwide requirement.

It is about to be, after a fashion. 

Note the subtle difference: it is only the 'first' train or locomotive to approach the switch that has to use restricted speed.  I'm pretty sure FRA will try to dictate a SPAF-like way to confirm and document the 'report to the dispatcher'.

Will be interesting to see what the FRA's new EO will explicitly call for the approaching crew to do if the switch in fact turns out to be mislined.  Reading between the lines the approaching conductor might 'correctly line' the switch if they find it wrong ... but it might just as easily follow blue-flag procedure with the train waiting for the 'original' man who was supposed to have lined the switch to return and 'correct' it -- then the approaching crew reports that it is right before proceeding.

I think this represents reasonable common sense in the circumstances, where a railroad's management decides it has to keep switching during a suppression.  It even covers the possibility of a signal-department or other employee changing the switch position after the original crew 'locks and docs' the switch. 

Not as safe as either spiking or mandatory restricted-speed approach, though.

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Posted by Overmod on Saturday, February 17, 2018 9:18 AM

BigJim
Not the way that I read it. This is not specifically about the the SC accident. It is worded in a way to bring context to the NTSB recommendation. Unfortunately, you are confusing the different noted scenarios on other RR's and superimposing them [on] the SC incident.

Actually no, the NTSB report clearly states the engineer 'ran to safety' and that the conductor 'saw the Amtrak train approaching ... ran to the rear of the locomotive ... was thrown off the locomotive and sustained minor injuries.'

I see no way to read this other than, as the report indicates, referring to the specific accident at "Cayce".

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Posted by tree68 on Saturday, February 17, 2018 10:01 AM

Euclid
Early in the thread called, Misaligned Track Switches That Cause Wrecks, I suggested that during signal suspension, switches should be approached at “Restricted Speed.”  But I was told no; that cannot be a proper solution because it would not permit meaningful transportation to take place.  I was told that the switch position verification forms were all that is needed.  Then as long as everyone does their job, everything will be okay. 

There is a huge difference.  This recommendation calls for only the first train past such a switch to approach at restricted speed, not all trains.  And it only calls for such action on a switch that has been used, not all switches.

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Posted by Lithonia Operator on Saturday, February 17, 2018 10:36 AM

I read that as meaning the Cayce incident.

Still in training.


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Posted by Euclid on Saturday, February 17, 2018 11:09 AM

 

The first section of the report comprised of the first three paragraphs is about the Cayce wreck.  But it does seem different than the original information conveyed about the freight train.  I would have to go back and read what it said in the initial report, but I was left with the impression that the freight crew had tied up and gone home.  They were simply not involved in the actual collision.  Now we are being told that both the engineer and conductor were on the freight locomotive as the Amtrak train approached the point of impact. 

 

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Posted by dinodanthetrainman on Saturday, February 17, 2018 5:01 PM

This + over reliance on automation is why I would never ride a hyperloop.

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Posted by Electroliner 1935 on Saturday, February 17, 2018 5:26 PM

dinodanthetrainman

This + over reliance on automation is why I would never ride a hyperloop.

Yet you get on an elevator with no operator. You drive on the highways in a car that weighs about 3,000 lb along side 60,000 lb trucks. And over one million people died on the highways last year. Have you been to Vancouver BC and been on their "SKYBUS"? It is automated and very sucessful. Let us get rational people. 

While I don't plan to be a test pilot nor scale the face of half dome, one has to understand risks and rewards. I don't play the Lottery because I took a course in Statistics and Probability and understand the odds. Life has chance. When you get up in the morning and step out the door, if it is icey, you may fall and break something or worse. Or if you live on the coast in Florida or Texas, a hurricane may wipe ypu out. So don't be the first to go on a hyperloop ride but don't say it is because of automation. Enjoy life. 

Also, remember what some people said about automobiles back in the late 1890's. And airplanes,  "Man was not meant to fly" When people tell me that nothing is impossible, I respond "I can definitly say that my getting pregnant IS impossible". 

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Posted by zugmann on Saturday, February 17, 2018 5:42 PM

dinodanthetrainman
This + over reliance on automation is why I would never ride a hyperloop.

does that issue come up much?

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

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Posted by PennsyBoomer on Sunday, February 18, 2018 1:15 AM

Once again it is another level of checking based upon events that have precipitated most all of the Rules. There were not Form B's protecting maintenance of way work until, I believe, the late 70s when a UP train got into an Ohio Crane fouling their right of way. The advent of the Form B has no doubt been of benefit but, prior to, it was flag and whistle. So this rule, appropriately, for a first train was inevitable in the event. 

I guess every remotely conceivable possibility must be provided for, to be safe; but if a switch is not lined the way it's supposed to be, with radio communication I suppose that could be worked out - everything at a stop as is, of course, safest. Hard to imagine trains blew through an active derailment site at maximum speed, freight 60, passenger 70, laying on whistle and flagmen blowing their shrill whistles. PRR of old. But there was a rigor to operations that seems to have elapsed in unfortunate cases such as this.   

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Posted by daveklepper on Sunday, February 18, 2018 1:59 AM

Any one ask the quesition as to why a whole page seems to be missing between 13 and 14, nothing for several days, almost a week.  I may be mistaked, but I believe I may have posted twice during that period.

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Posted by BigJim on Sunday, February 18, 2018 7:43 AM

Overmod
Actually no, the NTSB report clearly states the engineer 'ran to safety' and that the conductor 'saw the Amtrak train approaching ... ran to the rear of the locomotive ... was thrown off the locomotive and sustained minor injuries.'

Yes, I completely missed that. Duh!

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Posted by Euclid on Sunday, February 18, 2018 10:16 AM

Somehow, up until this latest news, I must have missed the reporting of the detail that the freight crew was on the locomotive and working their shift as the Amtrak train approached.  In all the earlier news since 2/4/18, I don’t recall any reporting that the freight engineer got off the engine moments before impact and the conductor ran to the back of the engine and was thrown off upon impact.

So, was the freight crew moving their locomotives and cars, and then stopped when they saw the headlight of the approaching Amtrak train?  Or were they standing there for a prolonged time?  Were they standing there waiting for the Amtrak train to clear?  Or were they pulling ahead and planning to pull through the open switch and back onto the mainline, thinking that the Amtrak train was being held, or was not close? 

Assuming that the CSX freight crew was waiting for the Amtrak train to pass; I wonder what their next move was intended to be after the Amtrak train passed.  It seems likely that they would have intended to shove the cars back or pull them ahead.  Standing still with both the conductor and engineer on the engine suggest that they were intending to pull the cars ahead.  If they were planning to pull the cars out of the siding after the Amtrak train had passed, why wait so far back from the switch?     

One possible answer to that question is that the freight crew believed that they had the right to re-enter the main line, and were pulling ahead with the cut of cars intending to pull through the switch that was lined for them, and then head onto the main line.  So they were not expecting the Amtrak train to be approaching at speed.  Then when they saw the Amtrak train approaching, they were still several hundred feet back from the switch; and they stopped right there and fled for safety.  That is why they were standing about 650 feet back from the switch.  That just happens to be where they were when the disaster revealed itself.  They knew the switch was open because they had intended to pull through it and enter the main line. 

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Posted by 243129 on Sunday, February 18, 2018 10:49 AM

'Someone' had to report clear for #91 to proceed.

 

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Posted by Euclid on Sunday, February 18, 2018 10:55 AM

243129

'Someone' had to report clear for #91 to proceed.

 

 

We know now that it was not clear for #91 to proceed. 

Did the freight crew know that #91 had been given the right to proceed?  Or did the freight crew believe that they had the right to proceed, and that #91 had not been given the right to proceed?

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Posted by Overmod on Sunday, February 18, 2018 11:21 AM

Euclid, in order for the dispatcher to release authority to 91, some very explicit things had to happen under EO 24:

1) The CSX crew had to make a joint, conscious decision to surrender formal track authority.  (It remains to be seen if anyone like the dispatcher called them requesting this for the delayed Amtrak train)

2) BOTH members of the CSX crew had to write down that they independently confirmed all switches to the main they had 'touched' were lined and locked for the main, as part of the post-Graniteville/EO 24 'standard operating procedure' for safe release of authority

3) Whoever was working the  would then have to confirm with the dispatcher, EXPLICITLY, not that the switch was lined and locked but that the FRA SPAF was filled out completely (thereby establishing not only that the switch position was correct but that BOTH the engineer and conductor independently confirmed 'on the record' that it was).  

Presumably there is a (4) where the dispatcher confirms that she received and noted the information necessary to permit release of the CSX authority, but that did not need to be confirmed with the crew giving up the authority.

Only upon receipt of this somewhat stilted confirmation was the dispatcher to release authority.  It is not clear to me that the FRA put much importance on the dispatcher then telling the CSX crew what the subsequent assignment(s) of the authority they released would be; my assumption in fact (as a non-railroader) would be that this would add needlessly to radio chatter, and add steps that FRA thought their formal procedure would make redundant.

I think that a great many of the Euclid questions being asked can only be answered by the results of the interviews conducted by the NTSB.  There is no possibility at all that the CSX crew could have followed the EO 24 procedure, whether or not they were unfamiliar with non-CTC operation, and still thought they had authority to touch, let alone foul or move through, any main-line switch.  

It was my understanding fairly early on that the CSX shove positioned the back end of the consist where it was expected, and that is why the train was stopped 'far back' at the time.  Again, I think we have to wait for a detailed account of what was being done on that siding and how the CSX crew might have been intending to 'do next' -- and I do expect the NTSB interviews to provide this, but I have not seen it yet.  Obviously we would not know about the engineer running from the point of impending impact or the conductor being thrown from the trailing locomotive if some analysis of interview material had not already been done.

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Posted by 243129 on Sunday, February 18, 2018 11:33 AM

I fail to see the point in filling out a paper form on site unless you have the means to fax it to the dispatcher. That form can be filled out at anytime. Again someone had to report clear of the main line. The question of the day is who reported clear and why was the switch not lined? The CSX crew has many questions to answer.

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Posted by gwyn68 on Sunday, February 18, 2018 11:39 AM
Or the despatcher?
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Posted by Euclid on Sunday, February 18, 2018 11:48 AM

243129

The question of the day is who reported clear and why was the switch not lined? The CSX crew has many questions to answer.

I think the question also includes; Who reported to the crew of #91 information conveying that the switch was clear?

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Posted by Overmod on Sunday, February 18, 2018 11:50 AM

The point of the 'paper' form and how and why it is used are covered quite adequately in the EO 24 discussions and final rule; you may want to review NTSB RAR 05-04 to see where the recommendations leading to EO 24 in its final form came from.  It was, and is, pretty clear to me wh is involved; it is also pretty clear that the revision in the wake of this accident to 91 is a sensible additional precaution against any residual 'miscommunication' that the EO 24 procedure did not prevent.

And it was very clear almost from the outset that some form of miscommunication or 'misdocumentation' had to be involved, specifically including a failure 'somewhere' to follow the EO 24 procedure correctly.  I have little doubt that the NTSB report will find, and detail, what that was; I have my suspicions but in the absence of evidence that's all they are.

The important thing here is not whether the dispatcher gets a facsimile or carbon or E-mail or whatever of the 'written' documentation.  It is that before the 'procedure' gets started there was a conscious decision by the CSX crew to begin it ... to completely release authority to enter or run on the main.  The paper form is a bit like a checklist in aircraft preflight (we know the NTSB is more than a little air-culture-centric  originally) in that it requires the crew to think about and state clearly that an important step has been completed, and as importantly to agree that it has.  Making this completion the 'confirmation' sent to (and presumably formally acknowledged as received by) the dispatcher -- I suspect the fine old railroad procedure of reading back full orders would work in context -- is just a different way to transmit as unambiguous a verbal confirmation as FRA thought at the time to meet the operational emergency posed by the Graniteville accident.

That it proved in this particular accident to be insufficient calls, more than almost anything, to find precisely where it was insufficient and fix those shortcomings.  In this sense the new EO is more a Band-Aid than a 'solution' -- although I agree that the idea of second physical confirmation of switch position is a common-sense addition to real safety and it should remain a full part of EO 24 enforcement no matter what other changes come out of NTSB and FRA as the result of investigation.

 

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Posted by Euclid on Sunday, February 18, 2018 11:55 AM

Overmod
There is no possibility at all that the CSX crew could have followed the EO 24 procedure, whether or not they were unfamiliar with non-CTC operation, and still thought they had authority to touch, let alone foul or move through, any main-line switch.

It was my understanding fairly early on that the CSX shove positioned the back end of the consist where it was expected, and that is why the train was stopped 'far back' at the time.

Yes, of course we will have to wait, but in the meantime, I will try to understand the details that we have been given as they are provided. My questions are purely rhetorical in order to find pieces of the puzzle that might fit, just to see what picture it paints.

Regarding the final position of the freight engines and their cars; Assuming that the crew knew the track was clear, would it have been typical practice for them to shove back blind with both crew members remaining on the engine?  If that were the case, why would they not pause and reline the switch as they shoved in?  The conductor would have been on the engine, so he could reline the switch as soon as they cleared the mainline.    

Regarding the theoretical infallibility of EO 24:  I am beginning to suspect that this procedure may not have been properly executed, in which case, the negligence may not be on the part of the CSX freight crew.

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Posted by Overmod on Sunday, February 18, 2018 12:18 PM

Euclid
Regarding the theoretical infallibility of EO 24:  I am beginning to suspect that this procedure may not have been properly executed, in which case, the negligence may not be on the part of the CSX freight crew.

Euclid, 100% of the "execution of the EO 24 procedure" IS 'on the part' of the CSX freight crew.  If you need to review EO 24 v2 perhaps you should do that now before the speculations run away with you again.

The only thing EO 24 adds to the dispatcher's 'responsibility' is to confirm that the SPAF is complete - nominally a yes or no question.  And all the responsibility for that answer ... not part of it, ALL of it ... is with the crew on the spot, not the dispatcher blind in JAX with all the secondary confirmation 'down' or unreliable.

Now, it may turn out that the crew cavalierly reported something that the dispatcher misunderstood, which I was ridiculed for suggesting as a potential cause early on.  But in light of the very specific things done and presumably enforced by FRA under EO 24, that is either incredibly unlikely or the result of near-incredible multiple violation of Federal mandate (and operational common sense).

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Posted by Euclid on Sunday, February 18, 2018 1:00 PM

Overmod
 
Euclid
Regarding the theoretical infallibility of EO 24:  I am beginning to suspect that this procedure may not have been properly executed, in which case, the negligence may not be on the part of the CSX freight crew.

 

Euclid, 100% of the "execution of the EO 24 procedure" IS 'on the part' of the CSX freight crew.  If you need to review EO 24 v2 perhaps you should do that now before the speculations run away with you again. 

Oh, I am not worried about my speculations running away with me.  But it would help if you would provide the explanation of the procedure in which authority is granted to and reliquished by the freight crew; and coresspondingly granted to and relinquished by the conflicting Amtrak train.  If this is not all EO 24, then my point may fall outside of EO 24.  In any case, I am referring to the process that involves input from the freight crew to the dispatcher, and output from the dispatcher to #91. 

All I am suspecting is that the freight crew never gave their input for authority to be taken away from them. 

 

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Posted by BaltACD on Sunday, February 18, 2018 1:18 PM

Euclid
All I am suspecting is that the freight crew never gave their input for authority to be taken away from them. 

To have been able to make ANY MOVE involving the Main Track - the Freight crew had to have been issued a EC-1 (TWC Authority) to occupy the Main Track in the particular TWC block.  There is a procedure that must be followed in the issuance and release of EC-1's.

To release the block back to the Dispatcher the crew would have to state (almost verbateum) "Y777-04 is releasing EC-1 ##### in the Cayce Block and all switches have been secured for Main Track movements".  The Dispatcher will repeat that verbiage back to the crew, for the crew to challenge any difference to their understanding.  Once the Dispatcher and the Freight Crew Agree, the block is released and it can be issued to another train by the Dispatcher.

The procedures ARE NOT - 'Hey Fred I want to shove 30 cars in the siding - OK Sam shove the cars off and let me know when you are clear.  Hey Fred we are clear.

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Posted by Deggesty on Sunday, February 18, 2018 2:46 PM

243129

I fail to see the point in filling out a paper form on site unless you have the means to fax it to the dispatcher. That form can be filled out at anytime. Again someone had to report clear of the main line. The question of the day is who reported clear and why was the switch not lined? The CSX crew has many questions to answer.

 

In the days before all the paraphernalia now in use to ascertain that everything is lined up properly, rveryone concerned trusted that whoever reported that certain actions had been taken told the truth, and that the actions had been taken. 

In this instance, it seems that the dispatcher trusted that what was told him/her about the switch was the true situation. The Amtrak crew trusted the dispatcher.

Had the system been in operation, the dispatcher would have trusted what the board showed, and the Amtrak engineer would have trusted the signals in front of the train.

The system for temporary operation under dark conditions is so set up that if its stipulations are followed, every one concerned trusts that all is well.

Johnny

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