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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by Euclid on Saturday, June 29, 2019 5:33 PM

As I mentioned on the previous page, I want to isolate the actual rules broken by the two victims; as opposed to various opinions about how advisable their activities were. 

So, I have established that there was no rule, special instruction, or any type of company edict that prohibited the two employees walking on the Amtrak track.

Also, there was no rule, special instruction, or any type of company edict that required the two employees to have protection while walking on the Amtrak track.

Their actual rules violation is addressed in the CSX Safe Way rules, which can be found at this link:

https://www.dot.ny.gov/main/business-center/designbuildproject/repository/CSXT_Safeway_2012_07-01.pdf

Refer to these quotes from the CSX Safe Way rules:

 

GS-10. On or About Tracks

When working on or about tracks:

• Apply the appropriate protection (3 –Step, Roadway Worker, Blue

Signal, etc.) for your job classification where required.

Be alert for and keep clear of the movement of cars, locomotives, or

equipment at any time, in either direction, on any track.

• Do not cross within 25 feet of the end of standing cars, equipment, or

locomotives, except when proper protection is provided.

• Stand at least:

- 30 feet or more from a switch or derail associated with the route of

passing equipment, when practical.

- 10 feet or more from a switch or derail being traversed by

equipment during switching operations when practical.

• Stop and look in both directions before making any of the following

movements:

- Fouling or crossing a track.

- Moving from under or between equipment.

- Getting on or off equipment.

- Operating a switch.

• You may cross more than one track without stopping at each track if you

determine it is safe to do so.

 

The only rule that the two employees violated was the one I highlighted in red:

Be alert for and keep clear of the movement of cars, locomotives, or equipment at any time, in either direction, on any track.

 

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

That is the extent of their rules violation that we know of.

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Posted by zardoz on Saturday, June 29, 2019 4:20 PM

AnthonyV

 

 
zardoz

 

 

..... Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor--

 

 

 

 

Again, I speak s a layman.  This sitution appears to be unusual in that the conductors were asked to inspect a train along side 95 mph tracks of another railroad in which trains are moving fast enough to kick up ballast (according to the engineer).  Whereever I have worked, we would have each other's backs regardless of our official title, duty, etc.  I know I've been in situations in which one of us (including me) was about to do something stupid and a collegue would catch it.

Of course you did. Most people would. I know I always did. But as I am unfamiliar with the track layout where it happened, did the Engineer have sufficient time to see a 95mph train and to warn his crew? Was there curvature or hills that would have kept the Engineer from seeing the approaching train until it was already too close? Would the train crew even have heard a warning over the radio due to engine noise? 

AnthonyV
I agree with the sentiment that the ultimate responsibility falls on the conductors, but I see nothing wrong with the idea of the engineer acting as a spotter to make sure the guys on the ground are aware of oncoming traffic.

it has been mentioned in this thread that the safest course of action should be taken.  Regardless of the mistake(s) made by the conductors, would it not have been safer if the engineer was calling out traffic to the conductors?

 

Of course; when possible. Just like calling wayside signals in the cab. And don't think that the Engineer hasn't thought a lot about these issues as well.
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Posted by zardoz on Saturday, June 29, 2019 4:03 PM

Convicted One
You did this stuff for a living, so tell me. If you had been the senior conductor, in this exact same scenario.....what would you do?

I never actually worked as a Conductor--I went from braking right in to engine service. At the time we were not required to qualify as a Conductor; even though as Engineer is also a qualified Conductor, the obverse is not true.

Having said that, if I was the Conductor, I'm not sure I would have let my 'trainee' walk by himself (depending on his level of experience); additionally, if the inspection was already done, why didn't the train crew ask the Engineer for permission to back up so they could be picked up WITHOUT having to walk along any track. And why didn't the train crew just drop off where the locomotives were to stop after crossing over? Did the train crew have to ride the point of the entire shove?

I also would not have been too eager to crawl through or under the train, at least until I had an absolute understanding with the Engineer. Heck, I didn't like having to crawl under my own locomotive, even knowing full well that I had secured the train beforehand.

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Posted by Convicted One on Saturday, June 29, 2019 1:24 PM

It would have been an option available to them, however, as an alternate to fouling the Amtrak main. Again, just in the spirit of "what if?"

Or, more in line with my original speculation pages earlier, they might have seen fouling the Amtrak main as less of an inconvenience than having to cross their own train (including whatever the rules might prescribe for such activity)

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Posted by charlie hebdo on Saturday, June 29, 2019 1:00 PM

Crossing your own train has nothing to do with  standing and walking on an active track of an adjoining railroad.  These rules may end up causing  confusion and less safety. 

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Posted by MMLDelete on Saturday, June 29, 2019 12:58 PM

As for the actual inspection, it was not on the Amtrak-adjacent track; that part of the train was still on the more distant track, I think. It was only the walk back forward, as they neared the part which had gone thru the crossover, which exposed them ... because, inexplicably, they did not cross the train.

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Posted by MMLDelete on Saturday, June 29, 2019 12:51 PM

I don’t get how 3-step protection can take any significant time to put in place.

I mean, yeah, if you need to wait til the engineer gets off the crapper, then add a few minutes.

How management could think this is too cumbersome is beyond me. And prohibiting it, to me, is criminal negligence. People will sometimes need to cross a train or a cut.

Compared to the delay that would have occurred had they actually set out the BO cars, it’s nothing.

 

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Posted by BaltACD on Saturday, June 29, 2019 12:39 PM

Overmod
Note that the request for protection, its effective provision and confirmation, and subsequent release of permission by the conductors would all be quick and positive if made over the radio.  (I do have to ask Balt if this would have had 'consequences' if three-step in this situation were officially prohibited at the time and the radio traffic was 'overheard'.)  This vs. what might be quite a while to invoke full protection on Amtrak via the likely mechanisms we've discussed.

All radio communications, and/or monitoring of radio channels by the Train Dispatcher are recorded.  The Road Radio Channel, as such, is not recorded.  A conductors request for '3 Step' most likely would not be heard on the Road Channel, even if the Dispatcher were monitoring it, the Engineers response most likely would be able to be heard.  Only a few Dispatchers make a habit of monitoring the Road Channel and even then it will only be done through one of approximately 10 transmitter/reciever stations that the normal Dispatcher's territory encompasses. ie. If the Dispatcher is monitoring a transmitter in the Brunswick, MD area, he will not hear radio traffic that is happening in the Washington, DC area.  When crews desire to talk to the Train Dispatcher, they 'tone in' and this creates a 'ring' on the Train Dispatchers Avtech Radio/Telephone computer console. 

Not having worked in the post-EHH enviornment I have no idea of any potential consequence for requesting 3 Step Protection.

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Posted by Convicted One on Saturday, June 29, 2019 11:37 AM

I guess there is no way of knowing with absolute certainty if the conductor who crossed over his own train as Balt mentioned, did so with 3 step, or any other form of protection, or not?

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Posted by Overmod on Saturday, June 29, 2019 11:09 AM

In order for the conductors to cross over the standing train safely, three-step should be observed.

Part of the non-shoulda-woulda-coulda here is that the conductors may not have recognized how tight the clearance near the front of the train would be when they 'joined forces' at the end of the train and started back up to the cab.  When they did realize, the 'safe course' for crossing the standing train would include three-step, here perhaps 'time-justified' even in EHH days because the train would not be expected to 'have to' move for several minutes at least 'either way' from the time of crossing over or under.

Note that the request for protection, its effective provision and confirmation, and subsequent release of permission by the conductors would all be quick and positive if made over the radio.  (I do have to ask Balt if this would have had 'consequences' if three-step in this situation were officially prohibited at the time and the radio traffic was 'overheard'.)  This vs. what might be quite a while to invoke full protection on Amtrak via the likely mechanisms we've discussed.

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Posted by Convicted One on Saturday, June 29, 2019 10:49 AM

Tangential curiosity. With all the effort expended in this thread thus far towards "coulda, shoulda, woulda".....It's just a small evolutionary step.Smile, Wink & Grin

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Posted by charlie hebdo on Saturday, June 29, 2019 10:43 AM

Maybe I missed something, but I  don't see what Three Step Protection has to do with this accident.

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Posted by Convicted One on Saturday, June 29, 2019 9:59 AM

tree68
I haven't heard much radio traffic on CSX in a while, but I think it may be back.

Sounds like even if the conductors had requested Three step protection, it would not have been immediately available.

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Posted by BaltACD on Saturday, June 29, 2019 9:24 AM

AnthonyV
 
zardoz 

..... Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor-- 

Again, I speak s a layman.  This sitution appears to be unusual in that the conductors were asked to inspect a train along side 95 mph tracks of another railroad in which trains are moving fast enough to kick up ballast (according to the engineer).  Whereever I have worked, we would have each other's backs regardless of our official title, duty, etc.  I know I've been in situations in which one of us (including me) was about to do something stupid and a collegue would catch it.

What you are overlooking - when the incident started the train was on CSX #1 track and separated from Amtrak by CSX #2 track.  The Conductor & Trainee performed their inspection while the train was on CSX #1 track and their findings were relayed through the Engineer and Dispatcher to CSX Mechanical and the original plan was to set the offending car(s) out to CSX #2 track.  The train was crossed over through Control Point F Tower from #1 to #2 track to make the setout.  Before the setout was accomplished, the plan changed and the car(s) would not be set out.  When this decision was relayed to the crew on the ground I doubt that the Engineer knew 'exactly' where his ground crew was - what he did know was that he WOULD NOT be moving the engines and train until his ground crew was back on the engine - as such it was a good time to answer natures call.  In returning to the locomotives the ground crew would not be inspecting the train for defects, they would just be walking to get back to the locomotives.

Unless notified by the ground crew that they would be walking back to the locomotives on the Firemans side (Amtrak Side) of the train he would have no knowledge of which side of the train the ground crew would be walking and thus have any need to be a 'lookout' for them

Employees involved in Class 1 train and engine service are not normally directly 'in person' supervised on the performance of their duties - they are expected to perform their duties in conformance with Operating, Safety and Train Handling Rules without having a continual 'watchdog' on their back.  The carriers do not have sufficient operating supervision to assign a 'watchdog' to each crew.

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Posted by Convicted One on Saturday, June 29, 2019 8:00 AM

BaltACD
If I recall correctly, after the original stop, the Conductor walked one side of the train (Engineers I believe) the Trainee walked the other side.   I did not read that a cut was ever made behind the car that was going to be set off on CSX #2 Main after the train was crossed over from #1 to #2 to facilitate the set off.  That being said, the Conductor somehow crossed from the Engineer side of the train to the Fireman's side of the train before the Conductor and Trainee began walking from their location 'back in the train' to the locomotives.  Whatever protection the Conductor used to make his crossover from the Engineers side of the train to the Firemans side could have been used for both the Conductor and Trainee to cross to the Engineers side to complete their return to the locomotives. In the pre-EHH days, personnel on the ground would make a radio request of th engineer for 'Three Step' protection - Locomotive Brake applied, Reverser centered, Battery field Switch Open to make a move 'into' or over the train or cut of cars (tie air hoses, cross from side to side etc.).  My understanding is that EHH and his operating methods eliminated Three Step protection.

I appreciate your answer.

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Posted by AnthonyV on Saturday, June 29, 2019 7:16 AM

zardoz

 

 

..... Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor--

 

 

Again, I speak s a layman.  This sitution appears to be unusual in that the conductors were asked to inspect a train along side 95 mph tracks of another railroad in which trains are moving fast enough to kick up ballast (according to the engineer).  Whereever I have worked, we would have each other's backs regardless of our official title, duty, etc.  I know I've been in situations in which one of us (including me) was about to do something stupid and a collegue would catch it.

I agree with the sentiment that the ultimate responsibility falls on the conductors, but I see nothing wrong with the idea of the engineer acting as a spotter to make sure the guys on the ground are aware of oncoming traffic.

it has been mentioned in this thread that the safest course of action should be taken.  Regardless of the mistake(s) made by the conductors, would it not have been safer if the engineer was calling out traffic to the conductors?

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Posted by CSSHEGEWISCH on Saturday, June 29, 2019 6:51 AM

Lithonia Operator

Why did EHH do away with the three-step protection?

 
Probably because he felt that it took too much time to set up.
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Posted by MMLDelete on Saturday, June 29, 2019 4:26 AM

Why did EHH do away with the three-step protection?

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Posted by BaltACD on Friday, June 28, 2019 10:09 PM

tree68
 
BaltACD
  My understanding is that EHH and his operating methods eliminated Three Step protection. 

I haven't heard much radio traffic on CSX in a while, but I think it may be back.

It may be back - but it was gone when the Ivy City incident happened.

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Posted by tree68 on Friday, June 28, 2019 8:28 PM

BaltACD
  My understanding is that EHH and his operating methods eliminated Three Step protection.

I haven't heard much radio traffic on CSX in a while, but I think it may be back.

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Posted by BaltACD on Friday, June 28, 2019 8:08 PM

Convicted One
 
zardoz
Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor 

You did this stuff for a living, so tell me. If you had been the senior conductor, in this exact same scenario.....what would you do?

Aren't there rules that prohibit crawling under the train, or climbing over a coupler unless the train has been secured?  I'm not sure of that, but I have a faint memory  that there might be a fairly elaborate proceedure involved.

(assuming there is no car nearby with an end platform spanning the car's width.)

If I recall correctly, after the original stop, the Conductor walked one side of the train (Engineers I believe) the Trainee walked the other side.  

I did not read that a cut was ever made behind the car that was going to be set off on CSX #2 Main after the train was crossed over from #1 to #2 to facilitate the set off.  That being said, the Conductor somehow crossed from the Engineer side of the train to the Fireman's side of the train before the Conductor and Trainee began walking from their location 'back in the train' to the locomotives.  Whatever protection the Conductor used to make his crossover from the Engineers side of the train to the Firemans side could have been used for both the Conductor and Trainee to cross to the Engineers side to complete their return to the locomotives.

In the pre-EHH days, personnel on the ground would make a radio request of th engineer for 'Three Step' protection - Locomotive Brake applied, Reverser centered, Battery field Switch Open to make a move 'into' or over the train or cut of cars (tie air hoses, cross from side to side etc.).  My understanding is that EHH and his operating methods eliminated Three Step protection.

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Posted by Convicted One on Friday, June 28, 2019 6:46 PM

zardoz
Plus, it's likely that the Engineer did not feel as though it was necessary to play 'lookout' for his experienced Conductor

You did this stuff for a living, so tell me. If you had been the senior conductor, in this exact same scenario.....what would you do?

Aren't there rules that prohibit crawling under the train, or climbing over a coupler unless the train has been secured?  I'm not sure of that, but I have a faint memory  that there might be a fairly elaborate proceedure involved.

(assuming there is no car nearby with an end platform spanning the car's width.)

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Posted by Euclid on Friday, June 28, 2019 3:19 PM

tree68
 
Euclid
They seem to be saying that protection was not required and they want it to be required.  So they recommended that it be required. 

 

Give the man a cigar!

 

Why?  It is certainly not a new position or conclusion on my part.

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Posted by tree68 on Friday, June 28, 2019 3:05 PM

Euclid
They seem to be saying that protection was not required and they want it to be required.  So they recommended that it be required. 

Give the man a cigar!

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Posted by Euclid on Friday, June 28, 2019 12:47 PM

tree68
 
Euclid

I don't see why someone would say they were not prohibited if they were prohibited under certain conditions. 

 

 

Were the conditions under which they would be prohibited spelled out in the NTSB report, other than in the recommendations?

 

I did not see conditions under which they would be prohibited from walking on Amtrak track spelled out.  They seem to be saying that protection was not required and they want it to be required.  So they recommended that it be required. 

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Posted by tree68 on Friday, June 28, 2019 12:05 PM

Euclid

I don't see why someone would say they were not prohibited if they were prohibited under certain conditions. 

Were the conditions under which they would be prohibited spelled out in the NTSB report, other than in the recommendations?

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Posted by Euclid on Friday, June 28, 2019 12:01 PM

I don't see why someone would say they were not prohibited if the were prohibited under certain conditions.  The question is not about the just the words, but what the words mean.  Not prohibited means just that; nothing more, nothing less. 

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Posted by BaltACD on Friday, June 28, 2019 11:12 AM

When I was working in the pre EHH days of CSX - the S word was supreme.

The S word = Safety.  If personnel stated that a particular action was not SAFE - then actions were taken to do what was necessary to have the action undertaken in a safe manner.  In the pre-EHH days, no company official wanted to have one of their employees injured if the employee had declared a work process 'unsafe' and the official had demanded the action be undertaken by the employee anyway; such a action would be a quick way to start collecting Railroad Retirement Unemployment for that official.

I understand the pre-EHH observance of the S word was eliminated in the post-EHH world of CSX. 

Is this incident a coincidence of the post-EHH view of safety on CSX? 

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Posted by tree68 on Friday, June 28, 2019 11:09 AM

Euclid
So basically, the employees were permitted to walk on the Amtrak track, and to do so without having protection. 

The NTSB didn't say that, either.  They said the employees were not prohibited from walking on the Amtrak ROW.  Nothing more, nothing less.

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Posted by Euclid on Friday, June 28, 2019 10:04 AM

 

tree68
 
Euclid
Why do you assume that the NTSB statement also includes the condition that protection was required in order for their statement to be true.

 

I don't.

 
Euclid
They did not say that. 

And neither did I.  Don't put words in my mouth.  You seem to be the one that's hung up on that.  NTSB only said that there was no prohibition against the crews walking on the Amtrak ROW.  Had they intended to include "without protection," they would have.

I would tend to believe that said statement was laying the groundwork for their later recommendation of mandatory protection.

 
Euclid
And earlier, you agreed that protection was only an option and not a requirement. 

 

Actually, I think that's the consensus here, as far as this particular incident goes.  

 

Okay, I am sorry.  I made that question confusing by the double negative.  My conclusion about the NTSB’s statement is this:

Operating crews were permitted to walk either on or near the Amtrak tracks.

Because NTSB did not include any condition of requiring protection, their statement is meant to be true without a condition requiring protection.

So basically, the employees were permitted to walk on the Amtrak track, and to do so without having protection. 

I am just trying to separate what was permitted from what would have been advisable.   

 

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