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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by Euclid on Wednesday, June 26, 2019 4:43 PM

Overmod
The next thing I expect will be taken up is the idea of 'sensing' where employees are (perhaps using some of the mechanisms that enable pervasive PTC) and have some sort of automatic method that imposes protection when the system detects actual or anticipated 'fouling'. Bella would just have loved it. Think of it as a PTC mandate for employees and not just trains.

Yes, that is certainly coming.  I would call it Positive People Control of PPC.  That would have automatically stopped the Amtrak trains at Ivy City when the empolyees entered the foul zone of the track. 

It would have also made sure the switch was lined at Cayce.

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Posted by tree68 on Wednesday, June 26, 2019 4:44 PM

Euclid
"Well it [the new NTSB rule] very likely would have saved their lives even though it would not have been necessary if they had stayed off that track.  But since they did walk on the track and were killed in the process, wouldn't it have been better with the new rule in place rather than not being in place?" 

Yes - absolutely.  It would have been better if the rule was in place and they did not walk on the track.

It would not have been better if the rule was in place and they walked on the track anyhow.

What part of they should not have been walking on 95 MPH mainline track do you not understand?

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Posted by Euclid on Wednesday, June 26, 2019 5:58 PM

tree68
 
Euclid
"Well it [the new NTSB rule] very likely would have saved their lives even though it would not have been necessary if they had stayed off that track.  But since they did walk on the track and were killed in the process, wouldn't it have been better with the new rule in place rather than not being in place?" 

 

Yes - absolutely.  It would have been better if the rule was in place and they did not walk on the track.

It would not have been better if the rule was in place and they walked on the track anyhow.

What part of they should not have been walking on 95 MPH mainline track do you not understand?

 

I understand your third point about not walking on the track.  I think I understand your first point.  But the second point is a little unclear. 

The rule we are talking about is the new rule proposed by the NTSB that would have required the two employees to have protection in order to walk in the track.  But it is still possible that they would have broken that rule by walking on the track without protection and gotten killed.  THAT outcome would not have been better than if no rule existed.  But I am not sure if that is the outcome you are referring to.

In any case, your second point could also mean that the rule was in place, they obeyed the rule and got protection, and then walked on the track without getting killed.  That would have been equivalent to your first point.

Say they walked on the track without mandatory protection and got killed.

Now say they walked on the track with mandatory protection and were not struck.

Wouldn't the second scenario be better than the first?

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Posted by tree68 on Wednesday, June 26, 2019 6:57 PM

I'll type this  r e a l   s l o w   so you can get it all:

It would have been better if they had not walked on Amtrak's ROW in the first place.

It's really that simple.

My second point was if the rule were in place, but they ignored it and walked the track anyhow, dying in the process.  The rule would  not have done its job.

I doubt you would walk down the middle of a busy road, in the rain, in the dark, in dark clothes, with your back to oncoming traffic.  Yet this is effectively what that crew did.

As I said before - if that rule were in place, they likely would have either ignored it ("it's only a hundred feet or so"), or changed their route so they did not have to go through the rigamarole of obtaining authority for the few minutes they would have needed it to get back to their power.

Of course it would be good if they got protection and didn't get hit.  That's a foregone conclusion.

But in the end, it would have been better if they had not walked on Amtrak's ROW in the first place.

 

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Posted by Convicted One on Wednesday, June 26, 2019 6:58 PM

243129
You did not read the report correctly.Read it again and then we can discuss it.

Actually, I am correct here, as Balt so has pointed out. I'll copy his reply to you here for convenience, it is exactly what I recall reading in the official report

"When the train was initially stopped for inspection it was ALL on CSX #1 Main track - the track furtherest from Amtrak.  Crew was instructed by CSX Mechanical personnel in Jacksonville that the car they had been instructed to inspect, MUST be set out.  After consultation with the Dispatcher and others involved in the decision, it was decided that the car would be SET OUT on CSX #2 Main track, the track adjacent to Amtrak.  Train was lined by the Train Dispatcher through the crossovers at Control Point F Tower from #1 Main to #2 Main with the Conductor and trainee staying on CSX property East of F Tower to make the cut beind the car that was going to be set out.  Before the cut was made, CSX Mechanical changed their instructions and said the car could continue to the next terminal on the train's route (Brunswick, MD).  With the change in plans, the Conductor and Trainee began their walk back to the locomotives."

 

Personally, I don't believe that CSX would enjoy being told they have to wait an hour before they can begin inspecting their own train, and I'll speculate that they might "not enjoy" it so much that they might be reluctant to ask in the first place...If you look at the added  operating costs that  nationwide compliance with such a rule would add to all railroads currently operating, I think that they would be forced into a rather dark position of contemplating "acceptable losses" other than monetary.

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Posted by Convicted One on Wednesday, June 26, 2019 7:04 PM

tree68
I'll type this  r e a l   s l o w   so you can get it all: It would have been better if they had not walked on Amtrak's ROW in the first place. It's really that simple. My second point was if the rule were in place, but they ignored it and walked the track anyhow, dying in the process.  The rule would  not have done its job.

But you're not looking at the postive side. If such a new rule were put in place, and the crew ignored it anyway, yet managed to survive, they could be terminated!!  Pirate

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Posted by tree68 on Wednesday, June 26, 2019 7:18 PM

Convicted One
But you're not looking at the postive side. If such a new rule were put in place, and the crew ignored it anyway, yet managed to survive, they could be terminated!!  

Bow

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Posted by 243129 on Wednesday, June 26, 2019 7:29 PM

Convicted One
If I read the report correctly, I don't believe that the CSX train was occupying either the crossover, nor the main closest to the Amtrak main, when the inspection began. So, if you have an entire main that your own railroad controls between the train to be inspected, and the foreign main....would you request protection on the foreign line on that basis?

They were adjacent to to main line of a foreign railroad without any form of protection as is in evidence by the fact that they were both killed by an AMTRAK TRAIN.

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Posted by 243129 on Wednesday, June 26, 2019 7:31 PM

Convicted One
Actually, I am correct here, as Balt so has pointed out. I'll copy his reply to you here for convenience, it is exactly what I recall reading in the official report

During the inspection process the CSX train occupied the track adjacent to the Amtrak main line.

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Posted by Euclid on Wednesday, June 26, 2019 8:32 PM

tree68
It would have been better if they had not walked on Amtrak's ROW in the first place.

It's really that simple.

My second point was if the rule were in place, but they ignored it and walked the track anyhow, dying in the process.  The rule would  not have done its job.

Of course it would be good if they got protection and didn't get hit.  That's a foregone conclusion.

But in the end, it would have been better if they had not walked on Amtrak's ROW in the first place.

Wouldn’t acquiring protection be just as good as not walking on the track without protection? Obviously more people will get protection if it is required rather than if it is just an option.

I don’t agree that refraining from walking on the track in the first place is better than walking on the track with protection.  They are equivalent.

Remember, we are considering future situations similar to what happened at Ivy City, and in some of those, it may be necessary to walk on Amtrak track or be within the kill zone.  And it is all kill zone on the Amtrak side of CSX track where the accident happened.

So refraining from walking on the track may not always be an option.

I don’t understand this resistance to the idea of mandating protection.  Everyone here seems to think that they should have asked for protection and used it for walking on the track even though protection was not required.  Then when there is talk of mandating protection which would further insure its use, people turn around and are suddenly against protection. 

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Posted by BaltACD on Wednesday, June 26, 2019 9:15 PM

Euclid
 
tree68
It would have been better if they had not walked on Amtrak's ROW in the first place.

It's really that simple.

My second point was if the rule were in place, but they ignored it and walked the track anyhow, dying in the process.  The rule would  not have done its job.

Of course it would be good if they got protection and didn't get hit.  That's a foregone conclusion.

But in the end, it would have been better if they had not walked on Amtrak's ROW in the first place. 

Wouldn’t acquiring protection be just as good as not walking on the track without protection? Obviously more people will get protection if it is required rather than if it is just an option.

I don’t agree that refraining from walking on the track in the first place is better than walking on the track with protection.  They are equivalent.

Remember, we are considering future situations similar to what happened at Ivy City, and in some of those, it may be necessary to walk on Amtrak track or be within the kill zone.  And it is all kill zone on the Amtrak side of CSX track where the accident happened.

So refraining from walking on the track may not always be an option.

I don’t understand this resistance to the idea of mandating protection.  Everyone here seems to think that they should have asked for protection and used it for walking on the track even though protection was not required.  Then when there is talk of mandating protection which would further insure its use, people turn around and are suddenly against protection. 

Nobody is against protection - protection was a available tool in this instance - it was a tool that was not used.  Just because something is 'required' by rule doesn't mean that those in the field will comply with that rule if they believe they can accomplish their goal in another way - that is the human animal.

Everybody talks about people that color inside the lines will never advance or get ahead in the world.  Rules are challenges that establish the lines - the adventurous human nature does not accept that the line is the limit of their activity.  Remember Columbust broke the 'flat Earth' rule when he sailed West from Spain.  The human conditions is predisposed to explore outside the lines.

 

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Posted by tree68 on Wednesday, June 26, 2019 9:26 PM

We're really talking about two different things here.

What happened.

What can be done to prevent it from happening again.

As to what happened, I feel it is entirely on the victims.  They made the choice to not seek protection, to walk on the tie butts with their backs to oncoming traffic, to not maintain situational awareness, to not seek a safer path back to the locomotive.  We know the result.

As for prevention of future incidents, as Balt notes, I don't think anyone is against codifying the protection that already exists.  If nothing else, as I've noted before, it may cause them to take a different path rather than go through the hassle of getting protection.  Such a rule must be limited to those occasions where it is actually necessary to foul an adjacent track.  Otherwise, every time a CSX train occupied main 2, protection would be required.

 

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Posted by Convicted One on Wednesday, June 26, 2019 9:51 PM

243129
During the inspection process the CSX train occupied the track adjacent to the Amtrak main line

But you skirted my question, so I'll ask it again: if you have an entire main that your own railroad controls between the train to be inspected, and the foreign main....would you request protection on the foreign line  on that basis alone?

Perhaps  the person who ordered the CSX  train to move  onto the main adjacent to Amtrak while the conductors were on the ground should have requested the protection you speak of?

Could there be a case of "too many cooks" involved here?

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Posted by 243129 on Thursday, June 27, 2019 7:10 AM

Convicted One
But you skirted my question, so I'll ask it again: if you have an entire main that your own railroad controls between the train to be inspected, and the foreign main....would you request protection on the foreign line on that basis alone?

In answer to the question you claim I skirted. Of course not. The inspection process involved the CSX train to occupy their track adjacent to Amtrak's main line. Their employees involved in the inspection process chose to physically occupy Amtrak's main line.They did not seek protection. They were killed during the inspection process were they not?

Convicted One
Perhaps the person who ordered the CSX train to move onto the main adjacent to Amtrak while the conductors were on the ground should have requested the protection you speak of?

I would say that decision would be made in the field.

Convicted One
Could there be a case of "too many cooks" involved here?

It is a case of poor vetting, poor training and poor supervision coupled with inexperience.

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Posted by CSSHEGEWISCH on Thursday, June 27, 2019 7:17 AM

One faulty assumption is that if another rule is added to cover this situation, it will always be obeyed.  As others have pointed out, this accident could have occurred even if such a rule was already in place.  The book of rules does not have to read like Sheldon Cooper's roommate agreement.

Another faulty assumption is that better vetting (whatever that word means) and better (tighter?) supervision would have prevented that accident.  Insuring that a person is properly qualified is NOT an absolute predictor of future behavior.  Short of adding an ATM or RFE to every crew, I can't think of what would constitute better supervision in a railroad context.

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Posted by 243129 on Thursday, June 27, 2019 7:49 AM

CSSHEGEWISCH
Another faulty assumption is that better vetting (whatever that word means) and better (tighter?) supervision would have prevented that accident.

Here let me help you out.

 
vet1
/vet/
 Learn to pronounce
verb
gerund or present participle: vetting
  1. make a careful and critical examination of (something).
    "proposals for vetting large takeover bids"
    synonyms: screen, assess, evaluate, appraise, weigh up, examine, look over, review, consider, scrutinize, study, inspect; More
    investigate, censor, check, redact, check out, check up on;
    probe, research, look into, delve into, dig into, search into;
    informalgive something a/the once-over, size up
    "they try to vet all the publications they sell"
    • investigate (someone) thoroughly, especially in order to ensure that they are suitable for a job requiring secrecy, loyalty, or trustworthiness.
      "each applicant will be vetted by police"
CSSHEGEWISCH
Insuring that a person is properly qualified is NOT an absolute predictor of future behavior.
Nothing is an "absolute predictor". Personnel experienced in railroad operations can assess a candidates acumen for positions in the 'field' much more accuratrely than an HR person who has only read about the job description and not experienced it.
CSSHEGEWISCH
Short of adding an ATM or RFE to every crew, I can't think of what would constitute better supervision in a railroad context.
There was a trainmaster on scene, somewhere, what did he accomplish? Why was he not on the ground supervising the inspection process?
I retired from Amtrak five years ago and I can tell you from personal experience that the training and supervision is abominable.  I would be willing to wager that 75% of the assistant conductors are incapable of coupling or uncoupling passenger cars or replacing a burst air hose. Most supervision is equally clueless. Engineer training is portrayed in human error accidents. Dupont WA, Frankford Jct, Chatsworth CA etc.
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Posted by Euclid on Thursday, June 27, 2019 8:06 AM

BaltACD
Nobody is against protection - protection was a available tool in this instance - it was a tool that was not used. Just because something is 'required' by rule doesn't mean that those in the field will comply with that rule if they believe they can accomplish their goal in another way

Aren't they more likely to use the protection tool if it is required by rule as opposed to not being required by rule?  Why does a rule need to be 100% effective in order to be justified?

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Posted by tree68 on Thursday, June 27, 2019 8:39 AM

Euclid
Aren't they more likely to use the protection tool if it is required by rule as opposed to not being required by rule?

Maybe.
Euclid
 Why does a rule need to be 100% effective in order to be justified?
This incident is a perfect example of that.  There are already rules in place that would have prevented this incident.  They were not complied with.

 

 

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Posted by tree68 on Thursday, June 27, 2019 8:43 AM

243129
There was a trainmaster on scene, somewhere, what did he accomplish? Why was he not on the ground supervising the inspection process?

The way I read the report, they weren't inspecting the train at the time of the incident - they were returning to the locomotive.  

And perhaps the TM would have been the set of eyes they needed to prevent being hit.  That really opens up a whole new can of worms.

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Posted by BaltACD on Thursday, June 27, 2019 9:01 AM

tree68
 
243129
There was a trainmaster on scene, somewhere, what did he accomplish? Why was he not on the ground supervising the inspection process? 

The way I read the report, they weren't inspecting the train at the time of the incident - they were returning to the locomotive.  

And perhaps the TM would have been the set of eyes they needed to prevent being hit.  That really opens up a whole new can of worms.

Notification of Supervision does not get them immediately on the scene of whatever the incident is.  As much as it may surprise some, they are human to, they don't necessarily live in the geographical location of the incident.  From personal experience, if you get Supervision on the scene within two hours of them being notified they were 'Johnny on the spot'. 

Employees must be expected to do the jobs for which they have been hired and for which they are being paid.

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Posted by Euclid on Thursday, June 27, 2019 9:02 AM

tree68
 
Euclid
Aren't they more likely to use the protection tool if it is required by rule as opposed to not being required by rule?

 

Maybe.

 
Euclid
 Why does a rule need to be 100% effective in order to be justified?

This incident is a perfect example of that.  There are already rules in place that would have prevented this incident.  They were not complied with.

 

 

 

 

No, there was an option to use protection, not a rule that required it.  This matter has been continuously blurred in this discussion.  I have asked several times for someone to show me the rule.  Nobody has yet to provide a reference to the rule that would have required protection to be used. 

Yes there are other rules that the employees may not have complied with.  But in my comments that you quoted, I was speaking specifically about the difference between have a rule requiring protection versus protection being optional.

You keep saying that rules have no benefit because they might be broken.  Under that weird logic, you could throw all the rules out the window.  Rules intended to mandate safe behavior are meant to make safe behavoir more common than it would be without rules.  What is wrong with that?  All I hear is that no rule will end ALL safe behavior, so rules are not worthwhile.

And remember, we are talking about rules that will govern what happens in the future in places like Ivy City.  So your assumption that the two victims would not have followed rules are not only overly judgmental, but they are also irrelevant considering that this same type of hazard could confront different people in the future. 

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Posted by 243129 on Thursday, June 27, 2019 9:57 AM

BaltACD

 

 
tree68
 
243129
There was a trainmaster on scene, somewhere, what did he accomplish? Why was he not on the ground supervising the inspection process? 

The way I read the report, they weren't inspecting the train at the time of the incident - they were returning to the locomotive.  

And perhaps the TM would have been the set of eyes they needed to prevent being hit.  That really opens up a whole new can of worms.

 

Notification of Supervision does not get them immediately on the scene of whatever the incident is.  As much as it may surprise some, they are human to, they don't necessarily live in the geographical location of the incident.  From personal experience, if you get Supervision on the scene within two hours of them being notified they were 'Johnny on the spot'. 

Employees must be expected to do the jobs for which they have been hired and for which they are being paid.

 

This from NTSB/RAB-1901

The engineer stopped the train at CSX MP 33.4, and the crew found and released a partially applied handbrake. Meanwhile, a local trainmaster (supervisor) was notified of the problems with the railcar and proceeded to meet the train at CSX MP 36.8. After discussions with the CSX dispatcher, the dispatcher and crew decided to set the car out of the train on to CSX main track 2 at the crossover switches at Control Point “F Tower.” The engineer and train crew planned to proceed slowly (about 10 mph) while the conductor and conductor trainee rode on the railroad cars.During the repositioning of the train, the CSX dispatcher told the crew of an additional defect at the 12th car. Once the train was stopped, the conductor and conductor trainee walked back to the 12th car, where they found a second handbrake that was partially applied.While the train was being inspected, the CSX dispatcher consulted with a representative from the mechanical department concerning the readouts from the defect detectors. The mechanical employee determined that the defects were not significant enough to remove the carsfrom the train. The cars were to be inspected at the next terminal.At 11:09 p.m., the CSX train dispatcher notified the crew that the cars were cleared to proceed. The two conductors walked to the head end of the train. The crewmembers were not near the Amtrak tracks when inspecting the defective cars; however, when the train was repositioned,the locomotives and the first car were adjacent to Amtrak main track 3. When the conductor and conductor trainee approached the front of the train that was stopped on the crossover track between the two CSX tracks, they moved toward Amtrak main track 3. The employees were struck by the southbound Amtrak train P175 near the trailing end of the first car of their train, a bout 350 feet from the locomotive. The engineer stated that he was using the restroom when he heard a passing train sounding its horn, and he heard the sound of ballast striking the side of his locomotive. About the same time, he heard a second train in that area, along with the sound of a horn and a bell.Moments later, a trainmaster boarded the lead locomotive of the CSX train. The trainmaster and the engineer discussed the status of the CSX train and other railroad-related topics. Minutes later, Amtrak crewmembers from the passing trains approached the CSX locomotive. The CSX trainmaster dismounted the locomotive to speak with the Amtrak employees, who advised him that an Amtrak train may have struck two people. The CSX engineer attempted to contact the two conductors via the radio but received no response. The CSX trainmaster then walked toward the rear end of the train where he found the struck conductor and conductor trainee on the tracks near the first car in the train.

There was a trainmaster on scene.

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Posted by tree68 on Thursday, June 27, 2019 11:08 AM

Euclid
No, there was an option to use protection, not a rule that required it.

Nobody has claimed anything else.

It was an option they did not choose to use.  Had they stayed off the Amtrak ROW, they would not have needed it.

You mention a rule that would specifically apply to "places like" Ivy City.  Odds are that wouldn't be a rule at all, but a timetable special instruction.

As I mentioned before, it's entirely likely that when faced with a 20-30 minute procedure to get protection, a crew might opt to 1.  Chance the 30 seconds or so they might be in harms way, or 2. Choose a different course of action.

Rules do have a purpose.  Most have been written in blood.  One reaches a point, however, where they become onerous, at which point they start getting ignored.

And remember the first rule:  When in doubt, take the safe course.  They didn't.

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Posted by AnthonyV on Thursday, June 27, 2019 11:34 AM

What role does an engineer play in a situation like this?  As a layman, it seems to me the engineer could/should act as an extra set of eyes and be in constant communication with those on the ground instead of being in the bathroom.

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Posted by MMLDelete on Thursday, June 27, 2019 12:51 PM

Aok they had to do was climb across their train. Instead the apparently decided that since their exposure would so brief they would use AMTK’s ROW. And then did not exercise due vigilance there. Very, very sad; but quite avoidable.

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Posted by zardoz on Thursday, June 27, 2019 2:54 PM

AnthonyV
What role does an engineer play in a situation like this?  As a layman, it seems to me the engineer could/should act as an extra set of eyes and be in constant communication with those on the ground instead of being in the bathroom.

Hey, when ya gotta go, ya gotta go; and when the other members of the crew are off the locomotive, it is a good time to go--no embarrassing sounds or smells to worry about. Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor--you might as well blame the person who set the offending handbrakes.

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Posted by Convicted One on Thursday, June 27, 2019 5:47 PM

243129
They were killed during the inspection process were they not?

I would imagine that by the time the mechanical guy had over ridden the dispatchers decision to set the car out, the conductors felt pretty far removed from any decision making process.  Obviously  situational factors were conflicting with one another among the decision makers....that often leads to apathy among those who have had the decision taken out of their hands eg "I just work here"

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Posted by 243129 on Thursday, June 27, 2019 8:13 PM

 

Safety and self preservation were not taken out of their hands.

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Posted by Euclid on Thursday, June 27, 2019 8:42 PM

From the report:

What does this mean?

“The operating crews were not prohibited from walking either on or near the Amtrak tracks.” 

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Posted by MMLDelete on Thursday, June 27, 2019 9:32 PM

What it means is that report writers feel the need to write stuff.

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