CSX Fatalities Probable Cause, Ivy City, DC

[BaltACD]

Convicted One

That link is paywalled, jfyi.

Thanks to our forum providers - no one else.  You would think, two years later, news is not news and no longer has 'monetary' content.

[243129]

Euclid

 

 

243129

 

Euclid

So crossing over without 3-step protection did not violate any rules:

 

 

So lack of common sense coupled with their poor vetting, poor training, poor  supervision, lack of experience and the incompetence of 175's engineer got them killed.

 

 

 

 

I don't follow you.  What are you concluding in regard to there being no 3-step available (if that is what the engineer meant)?  It sounds to me like they were using plenty of common sense as a substitute for the 3-step protection.  The engineer secured the train and told the conductors that it would not move without their approval. 

Just to be clear, this point about the 3-step has nothing to do with protection for being near the Amtrak track.  At least that is my understanding. 

If CSX had discontinued the use of 3-step protection, does that mean that empolyees would be required to not use it?  And if so, why would they require that?  For that matter, why would they have discontinued it? 

 

You stated in your post that three step protection did not violate any rules,ergo my response. You further stated that the engineer secured the train and told the conductors that it would not move without their approval which gives credence to my response.

[Euclid]

243129

 

Euclid

So crossing over without 3-step protection did not violate any rules:

 

 

So lack of common sense coupled with their poor vetting, poor training, poor  supervision, lack of experience and the incompetence of 175's engineer got them killed.

 

I don't follow you.  What are you concluding in regard to there being no 3-step available (if that is what the engineer meant)?  It sounds to me like they were using plenty of common sense as a substitute for the 3-step protection.  The engineer secured the train and told the conductors that it would not move without their approval. 

Just to be clear, this point about the 3-step has nothing to do with protection for being near the Amtrak track.  At least that is my understanding.  And as I understand it, 3-step was brought up to question whether the two employees broke a rule in crossing over their train, in addition to whatever rules they broke in not seeing #175.

If CSX had discontinued the use of 3-step protection, does that mean that empolyees would be required to not use it?  And if so, why would they require that?  For that matter, why would they have discontinued it? 

[243129]

Euclid

So crossing over without 3-step protection did not violate any rules:

So lack of common sense coupled with their poor vetting, poor training, poor  supervision, lack of experience and the incompetence of 175's engineer got them killed.

[Euclid]

This is from the transcript of the interview with the CSX engineer.  He says they did not use any 3-step protection because it was not available, but he does not explain why.  But he said he worked with the conductors over the radio and told them when it was okay to foul the equipment.  This starts out with a question by the interviewer and the engineer answers.  I conclude that no 3-step protection was needed for the either conductor to cross over the train.  So crossing over without 3-step protection did not violate any rules:

 

Did they tell you what they found, or what are

20

21 some of the conversations that occurred?

A. They told me that they inspected the car, found the

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handbrake, and found no tread build up, the brakes were released,

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everything looked good. Basically, you know, whenever I stopped

24

the train, because you can't get three-step anymore, I told them

it was okay to foul the equipment. I set the locomotives up so it

1

won't -- the train wouldn't move. And that's when I just climbed

2

on board and knocked the handbrake off and everything. Both times

3

I told them it was okay to foul 4 the equipment. 

[243129]

Convicted One

 

 

243129

With that mindset I hope you are not a T&E employee.

 

 

Let's leave the personal assessments out of the discussion, okay? There are a couple members here already who cannot seem to tender a difference of opinion without wrapping them in veiled personal attacks...we don't need more of them.

 

No veiled personal attack or assessment intended. Your statement elicited that response.

[Convicted One]

243129

With that mindset I hope you are not a T&E employee.

Let's leave the negative personal assessments out of the discussion, okay? There are a couple members here already who cannot seem to tender a difference of opinion without wrapping them in veiled personal attacks...we don't need more of them.

[243129]

Convicted One

 

 

243129

your own train is immobile and cannot proceed without your permission and a safe alternative is available????

 

 

I'm sorry that I can't give you the answer that you want.  If the engineer was indisposed and did not answer my radio, with my patienced already stretched thin with the "dynamic decision making" relating to  the set out or don't set out  of the cars...I probably wouldn't want to wait to resolve the communication issue with the engineer.

Mind you, I'm not blaming thre engineer for the mishap, I'm just saying with him in the can when the Amtrak train went by, It's a good bet he would not have been in a position to give me the over the air reassurance that I would require in order to deem crossing over my own train to be a "safe" alternative.

 

With that mindset I hope you are not a T&E employee.

[Convicted One]

243129

your own train is immobile and cannot proceed without your permission and a safe alternative is available????

I'm sorry that I can't give you the answer that you want.  If the engineer was indisposed and did not answer my radio, with my patienced already stretched thin with the "dynamic decision making" relating to  the set out or don't set out  of the cars...I probably wouldn't want to wait to resolve the communication issue with the engineer.

Mind you, I'm not blaming thre engineer for the mishap, I'm just saying with him in the can when the Amtrak train went by, It's a good bet he would not have been in a position to give me the over the air reassurance that I would require in order to deem crossing over my own train to be a "safe" alternative.

[243129]

Convicted One

Me personally, I'd hate to be positioned in a vulnerable spot and then hear two longs on the horn and the slack start running out.

Unless the engineer is a complete moron the train should not move without permission from the ground crew. The entire (2) ground crew was together so there was no way the train would proceed unexpectedly.

Convicted One

I would see my only alternative to be to walk around the left side of the train....most likely on the Amtrak main

 Where trains are traveling at speeds in excess of 100MPH  and your own train is immobile and cannot proceed without your permission and a safe alternative is available????

[Convicted One]

That link is paywalled, jfyi.

[BaltACD]

https://trn.trains.com/news/news-wire/2017/07/14-csx-abolishes-several-operating-rules

Remember EHH came to power 03/01/17

[Convicted One]

243129

How could the engineer make a move without his crew knowing about it? That is a major no-no.

Me personally, I'd hate to be positioned in a vulnerable spot and then hear two longs on the horn and the slack start running out.

Balt has stated that 3 step protection was not required on CSX at the time of the incident. And although I can find no official source that would confirm this,  given Balt's experience and impeccable record of constructive contribution to this forum,  I'm willing to give him the benefit of the doubt.

Notwithstanding that, I see nothing in his comment that would prohibit the conductors  from establishing  contact with the engineer to arrange an understanding that they  were about to enter the guage of his train.

I would not cross over without a clear verbal understanding with the engineer,...and lacking any such confirmation .....I would see my only alternative to be to walk around the left side of the train....most likely on the Amtrak main given how many comments I've read on this forum over the years complaining how uncomfortable walking the ballast for any  appreciable distance is.

[Overmod]

Euclid

It is not clear to me where the actual red zone is located.

The CSX rules you quoted have the longitudinal red zone at 25' (rather than 10' as I had been saying).  Note that this would only apply to the 'blue flag' situation where the train is locked down from moving.

Euclid

But in any case, even if only the foul zone is the red zone, how can you ride a car while hanging on a ladder and stirrup?

The situation is different: the 'red zone' prohibitions only apply when working with the train stopped.  (Or, presumably, when avoiding the moving train rather than interacting with it is in the relevant 'job description') 

I would be highly interested in a comparison of pre- and post-EHH rules on what constitutes the safe zone and speeds when boarding and stepping off equipment.  This with particular emphasis on procedures in flat switching, where I believe it was becoming more and more common to expect switchmen to get off cars or engines onto gravel at what might be up to 10mph.

[Euclid]

Overmod,

Thanks for those explanations.  I am not advocating any expanded use of 3-step protection.  However, lately here, there has been the emergence of the issue that one of the two employees crossed over the train without there being 3-step protection in place.  I am just wondering if this actually happened and if it was a rule violation.  It is not clear to me where the actual red zone is located.  I can certainly understand the advantage of 3-step protection for going under the cars to couple air hoses.  But is it necessary for crossing over on the end platforms above the couplers?

I found one source that said that the 3-step red zone extends out 4 ft. from the nearest rail of the train on which the cars are standing. That is beyond the foul zone.  But in any case, even if only the foul zone is the red zone, how can you ride a car while hanging on a ladder and stirrup? 

[Overmod]

Euclid

If employees are going to inspect a train for reported defects, wouldn’t 3-step protection be required and executed right at the onset of that inspection?  Why would 3-step not be established immediately upon stopping the train after the two employees got off?

The point of three-step is the same, in general, as blue-flagging: it is for when people need to be in the gauge or fouling equipment.  That is explicitly not the case for a typical 'inspection' of the train after a reported detector incident (here almost certainly a hotbox detector picking up the IR signature due to the dragging handbrakes and not discriminating tread heat from bearing heat as newer ones can) where the whole object is to stay safely "outside" looking in as you go.

Something I think should be avoided is overuse of three-step as 'expected at every stop', although a case could be and probably has been made to implement it thus.  One potential issue has been discussed (IIRC by Jeff and some others): that any trapped slack after a braked stop might unexpectedly release and push some part of the consist.  Employees 'relying' on three-step to keep the train from moving would tend to be surprised by this, almost certainly unpleasantly.  Meanwhile the mechanical action on the engine is more complicated than you may think, and I think there's always some risk that one of the 'steps' may not undo properly when you want to apply power again (particularly in a world in which up to four power assemblies on a 16-cylinder engine can be known bad and the engine still used in service).  So what I, personally, advocate is the counterpart of the procedure for asking for civil protection on the ROW: that a rule be established that anytime a crew wants three-step they can request it over the radio, and the engineman will as promptly as possible provide it and confirm over the radio, repeating as necessary or using unmistakable code if there is high ambient noise.

Again in my opinion three-step is for when employees will be crossing or working under equipment, not any time they're on the ground (say, going to throw or check a switch).  On the other hand, I think it should be implemented any time the engineer is not vigilant at the controls (including any time whatsoever out of the cab) and that would include time on the 'crapper' -- might need to implement the corresponding ten-code over the radio to let the crew know "what's goin' down" without explicit embarrassment).  Please note that this is completely different from the employee request-and-receive procedure ... and that a crew requesting three-step 'while the engineer is indisposed' would have to wait for communication and confirmation before ASSuming anything.

The train is going to be stopped with air set.  Employees may have to go between cars to access handbrakes or other purposes.  So right at the start of the inspection, why not center the reverser and open the generator field switch, and announce 3-step protection is in place?

Perhaps partly because I am a non-railroader, I tend to agree with the idea that when someone goes in to release a sticking handbrake, particularly one that has been 'run hot' and may need special attention -- it remains to be seen if the NTSB is smart enough to look into why those two brakes weren't fully released in the first place, too -- they have effective protection against unexpected train movement to the greatest extent practical.  And part of that 'practical' can certainly be three-step.  But I'd have to leave it up to people that actually have to do it to determine the extent to which it's advisable, or why it wouldn't be.

Now, my understanding (possibly very mistaken) was that the 'inspection' was less required than a matter of convenience, while primarily going back to make the 'cut' to leave the deflicted car "set out" on the other main.  (I had the impression that the 'second applied brake' was found during this, so the conductors were doing their job).  The question I think you should ask is whether three-step should have been observed before the conductors cut the car off -- I'd expect they'd go in and secure its handbrake thoroughly, turn the corresponding angle cock on the car ahead, and perhaps even do a quick pull test, before pulling the cut lever; it might be worthwhile for someone to describe the exact procedure that would have been used in the particular situation at Ivy City.  At that point I'd think you'd implement three-step, then take it off relatively quickly by mutual communication before the train pulled away from the cut-off car and started up to cross over again to rejoin the sections of consist.

Let me reiterate here that I believe a certain amount of Mickey Mouse priority-changing regarding this 'setout' is almost certainly a major contributor to this accident.  I have not checked the NTSB docket to see if there is a transcript of the radio traffic -- that should be checked to see how the reason for the change in priority was communicated to the conductors.  I do hate to do the lawyers' work for them, but a known primary cause of inattention can be unrelieved job frustration.

 

[Euclid]

If employees are going to inspect a train for reported defects, wouldn’t 3-step protection be required and executed right at the onset of that inspection?  Why would 3-step not be established immediately upon stopping the train after the two employees got off? 

The train is going to be stopped with air set.  Employees may have to go between cars to access handbrakes or other purposes.  So right at the start of the inspection, why not center the reverser and open the generator field switch, and announce 3-step protection is in place?

I will have to re-read the engineer’s interview, but do we know for sure that 3-step was not in place during the entire inspection?  If so, how do we know that? 

[243129]

Convicted One

 

 

243129

 

 

One that is hardwired into his workstation.

 

 

 

 

 

Well, just being honest, but if I've been on my feet a couple hours, and am anxious to get back into the comfort of the cab, and could get no confirmation on the radio that the engineer was not about to make a movement that I would regret......I'd probably do the same thing the guys in the story did. Hopefully with a little more caution....but that is hindsight.

 

How could the engineer make a move without his crew knowing about it? That is a major no-no.

[Euclid]

I am just curious. Is three-step protection needed to cross over on the end platform of a covered hopper, for instance? 

[MMLDelete]

AnthonyV

 

 

Euclid

What is the basis for knowing that the two conductors crossed over their train?  When and where did this happen?

 

 

 

The report states that "....the conductor dismounted on the south (left) side of the train while the conductor trainee dismounted on the north (right) side of the train."

The two conductors dismounted on opposite sides of the train and ended up on the same side.  If I am reading this correctly, they were hit on the south side of the train, which is the side the conductor dismounted, suggesting at some point the trainee crossed over to the side of the conductor.

Actually, it proves that the trainee crossed over. And that happened safely. I don't know if the engineer knew he crossed over; and if not, then the trainee acted dangerously, but nonethless got a safe outcome.

Regarding the earlier post: as far as I know, no one is suggesting that both men crossed over. The conductor was already on the south side.

If, instead, the conductor had crossed over to be on the north side with the trainee, we would not be having this discussion. It would have been the same basic scenario: one man crossing over. The conductor was 25 years old; assumedly he was fit and agile enough to cross over. (The trainee was 20.)

Such a sad tragedy.

[AnthonyV]

Euclid

What is the basis for knowing that the two conductors crossed over their train?  When and where did this happen?

The report states that "....the conductor dismounted on the south (left) side of the train while the conductor trainee dismounted on the north (right) side of the train."

The two conductors dismounted on opposite sides of the train and ended up on the same side.  If I am reading this correctly, they were hit on the south side of the train, which is the side the conductor dismounted, suggesting at some point the trainee crossed over to the side of the conductor.

 

 

[Euclid]

What is the basis for knowing that the two conductors crossed over their train?  When and where did this happen?

I have not assimilated all of the details of what transpired after they first got off while their train was moving.  I know that there was insepction, finding handbrakes set, a call for setting out a car or cars, a change of plans, and moving the train to a second location with the conductors riding on the cars.  Then there was walking up to the head end. 

[MMLDelete]

243129

Rules notwithstanding. You are presented with a situation that requires a decision.

Option #1 is to transit 600(?) feet to your locomotive via a live track that belongs to a foreign railroad where trains can travel in both directions at speeds in excess of 100MPH.

Option#2 is to cross over to the opposite side of your train where there is no chance of traffic because both tracks are occupied by your train.

Which option do you take?

 

I agree. To me it's that simple. #2 is the only safe option.

Now, there seems to be suggestion in this forum that the conductors were not able to make radio contact with the engineer; and obviously they would have had to do so to ensure that they could safely cross their train.

I don't have time to re-read the report right now. Was there evidence or testimony that the men on the ground tried to contact the engineer but could not? If they called while he was using the toilet, then obviously they would have had to wait and try again.

If they had contacted him, how long would it have taken to set up three-step protection? I don't know engines enough to understand exactly what is involved; but from what I read here, it does not sound like something that would take much time.

Regardless, they should have waited, however long it took, to get protection on their own railroad. And then cross their train.

[Convicted One]

243129

 

 

One that is hardwired into his workstation.

 

 

Well, just being honest, but if I've been on my feet a couple hours, and am anxious to get back into the comfort of the cab, and could get no confirmation on the radio that the engineer was not about to make a movement that I would regret......I'd probably do the same thing the guys in the story did. Hopefully with a little more caution....but that is hindsight.

[243129]

Convicted One

 

 

243129

Which option do you take?

 

 

 

What type of radio is typical for an engineer? A portable handheld unit, or one that is hardwired into his workstation?

 

One that is hardwired into his workstation.

[Convicted One]

243129

Which option do you take?

 

What type of radio is typical for an engineer? A portable handheld unit, or one that is hardwired into his workstation?

[243129]

Rules notwithstanding. You are presented with a situation that requires a decision.

Option #1 is to transit 600(?) feet to your locomotive via a live track that belongs to a foreign railroad where trains can travel in both directions at speeds in excess of 100MPH.

Option#2 is to cross over to the opposite side of your train where there is no chance of traffic because both tracks are occupied by your train.

Which option do you take?

[Euclid]

Overmod

You seem to have missed the big one:

 

Euclid

• Stop and look in both directions before making any of the following movements: - Fouling or crossing a track.

 

 

It is also reasonably accurate to say

 

Euclid

We know that they violated that rule during the last ten seconds of their lives.

 

 

It is interesting to speculate why there is no 'combination' rule that says one should exercise constant vigilance to 'keep clear' when continually 'fouling ... a track'.  That is one of those things so glaringly self-obvious that I suppose I can understand why CSX had not formulated such a thing explicitly.   

 

 

I understand your point, but I thought long and hard about the "stop and look in both directions before fouling a track" part of the rule.  First of all, the rules do not say how to maintain a lookout while walking on the track lengthwise with it. 

So I just let that be covered by the "be alert for and keep clear of the movement..." part of the rules, as I quoted.

They did foul a track, but the fouling apparentely was continued rather than just momentary as would be the case with crossing a track. But I am certain that when the fouling began, they looked in both directions before fouling.  Anybody naturally would.  It would be effortless.   

So they looked both directions, and it was clear, so they started walking down the track.  The rule is mute on what to do next.  I would say that basically a person should look back often enough to not give time for a train to come up from behind without being seen.   

I suspect they did look back often.  In any case, we do not know that they failed to look back for any of the walk except for the last ten seconds or so.  That was the time in which #175 was approaching in sight.  If they had looked back then, they would have gotten out of the way.  So we know they did not look back during the last ten seconds, and we also know they were not alert to all trains during that same period.  They were alert to #66, but not to #175.

It may be that they were not looking back often enough and thus leaving themselves vulnerable between looks.  Then in the last ten seconds, they were in one of looking ahead phases of the look back/look ahead cycles.  I think that with the train speed potential on that track, they should have looked back every 5 seconds.  It would be more work than just walking in the clear on the ballast.

However, I suspect that it is also quite likely that the reason they did not look back during the last ten seconds was that they their attention became riveted on #66 as it approached from their front during that last ten seconds.  They heard #66's blowing the horn, and their first impulse would be to wonder which track that train was on.  They probably spent at least the first 5 seconds resolving that question.  Obviously, during that critical evaluation of which track #66 was on, they were completey focused on that train and had no thought of looking back to make sure it was clear behind them. 

The natural inclination is to expect one train when you are expecting trains.  Then when one arrives, a person would naturally let their guard down a little because it is unusual to have two trains arrive at the same second.  So when the first train arrives, the mission to keep a lookout for trains feels fulfilled. This is where the deadly illusion caught up with them. 

Balt, as far as wanting to know what they were thinking; I feel that due to the peculiar circumstances of this accident, we acutally do know exactly what they were thinking.  The whole illusion is competely undstandable as logical cause and effect.  It reads like a book.  The NTSB clearly saw it and clearly explained it just like I am explaining it.

The two victims saw a train coming toward them.  They wondered which track it was on.  They were completely distracted by it.  They heard the horns of both #66 and #175.  But becuse their attention was locked on 175, they never looked back.  It was only ten seconds.  Although they heard the horns of both trains, they did not see 175, so they assumed that the horns they heard were only the horn of 66.  I am sure that they might have had a variety of other unrelated thoughts, but the thoughts that explain the accident could not be more clear, in my opinion.

I am not sure why you ask, "What were they thinking?"  But if you want to know that in order to understand why they did not get out of the way, I think that is actually self-expanatory in this particular accident.

The way I see it, this accident involved two trains.  The employees were only struck by one, but the accident would not have happened if #66 did not approach at exactly the same time.

[BaltACD]

Unless and until technology is able to download and make understandable the final seconds and minutes of each of the deceased brain waves and thoughts we will never be able to answer the critical question - 

What were they thinking?

[Overmod]

You seem to have missed the big one:

Euclid

• Stop and look in both directions before making any of the following movements: - Fouling or crossing a track.

It is also reasonably accurate to say

Euclid

We know that they violated that rule during the last ten seconds of their lives.

It is interesting to speculate why there is no 'combination' rule that says one should exercise constant vigilance to 'keep clear' when continually 'fouling ... a track'.  That is one of those things so glaringly self-obvious that I suppose I can understand why CSX had not formulated such a thing explicitly.