CSX Fatalities Probable Cause, Ivy City, DC

[Convicted One]

That link is paywalled, jfyi.

[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]

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

 

 

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

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

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.

[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

22

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

23

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]

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]

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

 

 

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.

[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.

[Euclid]

243129

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.

I said that crossing over their train without 3-step did not violate any rules, if three step was not available to use.  

I said this: “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.”

The question I have is this:  What did the engineer mean when he said, “…you can't get three-step anymore” ?  Whatever he meant by that comment, it sounds like he and the two conductors did everything that would constitute 3-step protection.  I do not interpret the engineer to be saying that they simply ignored the use of 3-step when it was required. 

[Euclid]

It seems to me that there are two issues about how this accident relates to the Amtrak track. 

1)  Fouling the Amtrak track

2)  Occupying the non-fouling space between the Amtrak track and the CSX track.

 

The two conductors did both.  The NTSB believes they should not have been allowed to foul the Amtrak track without protection, but they say nothing about occupying the non-fouling space between the tracks. 

The work performed by the two conductors did not require fouling the Amtrak track, but it may have required occupying the non-fouling space between the two tracks. 

If they had performed their inspection earlier at the other locations, there may not have been any need for them to be on the Amtrak side of the CSX train at all while at the accident site.

However, any day could have brought forth the need in the past, or may bring forth the need in the future to inspect standing trains at the location of this accident.  In such a case, what if the employees chose to do their work without fouling the Amtrak track?  Should they still be required to have protection in order to work in the non-fouling space?  Should they have protection to be in this space where they would be in the clear of; but only inches away from Amtrak trains passing at 125 mph?  If the answer is yes, then employees would be required to have protection for being anywhere on the Amtrak side of their train.

The engineer said he forgot to warn them about being careful of Amtrak trains.  Is that warning all they would have needed?  It might have saved their lives, but is just a warning from a coworker enough protection for working in such a lethal zone?

So, how can CSX run a railroad that requires their employees to step into a death trap with no requirement, rules, bulletins, or special instructions warning them to obtain protection before entering into what to them might seem like just another rightly accessible area along their mainline? 

[Overmod]

Euclid

what if the employees chose to do their work without fouling the Amtrak track?  Should they still be required to have protection in order to work in the non-fouling space?

There are actually two questions here.  Obviously they have a 'right' to be anywhere on CSX property.  Whether it is advisable to 'encroach' on what might be considered the red zone of an immediately-adjacent railroad is a question, specifically, for CSX rules to address -- or for NTSB to 'recommend' in its reporting.

Should they have protection to be in this space where they would be in the clear of; but only inches away from Amtrak trains passing at 125 mph?  If the answer is yes, then employees would be required to have protection for being anywhere on the Amtrak side of their train.

The issue here is a bit more restricted: most of the problem with being 'too close' to Amtrak trains came in the last few feet, where employees eager to get back aboard the train might not recognize as sufficiently dangerous to go through the whole protection rigmarole (here, either to get the adjacent track completely clear of trains, which seems excessive for T&E as opposed to MOW, or have Amtrak operate on that track at reduced or even restricted speed) when the cab is so visibly near.  I would tend to doubt that any 'mandate' compelling protection in such cases would be observed rigorously "enough" by employees in comparable situations.  We are left with specifying the opportunity, and training employees not to be 'reluctant' to use it.

The engineer said he forgot to warn them about being careful of Amtrak trains.  Is that warning all they would have needed?  It might have saved their lives, but is just a warning from a coworker enough protection for working in such a lethal zone?

This is another question entirely.  I'd think (as a non-railroader who has participated in developing training methods) that this is an obvious topic for one of those fad 'five-minute safety meetings' either before the work day begins or just before starting a particular task.  The immediate problem is that, for crews working out of Ivy City, proximity to high-speed traffic is frequent, and almost as soon as the 'precaution' is repeated at every Mickey Mouse safety meetinglet, it begins to lose its force just as repeated reading of the safety procedures on aircraft does.  Being repeatedly reminded of something does not guarantee mindfulness.

So, how can CSX run a railroad that requires their employees to step into a death trap with no requirement, rules, bulletins, or special instructions warning them to obtain protection before entering into what to them might seem like just another rightly accessible area along their mainline? 

I am tempted to answer "vetting, training, and oversight" (as those answer most of the question) but that doesn't address the larger question of what rules CSX might use to enhance critical safety in this particular sort of situation.  This almost necessarily presuppose that the unions have established some form of safety awareness training that isn't foisted by weed weasels, as that's almost a precondition to address the problems in the Ivy City accident -- the following is strictly what CSX might do for CSX.

1)  Formally establish an effective 'red zone' for 125mph traffic, and coordinate (with the unions' programs) to make sure employees are trained to know the 'sight picture' for the spatial limits of that zone.  (In your particular example, if that red zone extended all the way to the side of a standing train, a conductor would act accordingly)

2)  Formally establish the procedure to be followed when an an employee enters, or expects to enter, such a red zone in the performance of duties.  That SPECIFICALLY would include a brief safety recap of the particular dangers, and radio communication authorizing safe crossing of the train or other actions to avoid encroaching on the red zone -- here, ensuring the engineer would not move the train or allow slack action to move it during the known time employees were crossing it.

3)  Formalize a chain of command, and actions to be taken, to provide appropriate protection for employees who must go into the red zone.  This would NOT be something automatically imposed any time some artificial separation distance were imposed; in my opinion it should be voluntary but provided without argument if requested.  

NTSB, if the issues leading up to the Cayce wreck are any indication, would impose some Mickey Mouse paper regulations, involving a log by the engineer, dispatchers, etc. that they received a Protection Request at time xxxx and took yyyy actions at subsequent times zzzzz, etc.  I suspect they would be no more effective, or useful, or valued by employees, than the restrictions at Cayce.  I don't expect Government agencies to learn from experience, but it would be refreshing if they'd try.

4)  As noted above, the necessary 'protection' is different for a T&E protect than for MOW, and the formal procedures could and should reflect that.  I have to wonder whether 'time and track' protection could be adapted to this, so an employee could pre-request protection in a particular location and window of time, and then be assured of receiving it.

All of this would apply to red-zone encroachment, not to actual fouling on Amtrak property, for which protection MUST be secured at any time, no matter how short or for fouling however perceived as slight.  I leave it to the railroaders here to comment on whether speed restriction alone, or 'proceed aware of people on the ROW', constitutes adequate protection if employees 'know' to keep a safe lookout when off their own property.

[jeffhergert]

Lithonia Operator

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.

 

 

It depends on how the procedure is written and viewed.  Even without the formal 3 step procedure, I'm sure there is still a rule about understanding between crew members.  Our red zone is contained within that rule.  I would guess that three-step was contained in a version of that type rule.  Taking away the formality of a procedure does not necessarily take away the entire rule it's contained in.

Our red zone procedure has been loosened up a bit.  Not in the practice, but in how it is established.  As originally written, it had to be only secured over the radio.  Even if the conductor and engineer in the cab established the zone in a face to face job briefing, it still had to be announced over the radio.  That has nothing to do with safety.  It's more about making a safety procedure into a chance to have a disciplinary action.  Now red zones can be established again by face to face briefing or hand signals.  

Before red zone, we had rules about understanding between crew members who had to foul equipment.  We had hand signals and radio terminalogy to keep crewmembers safe when fouling equipment.  If red zone should go away, we'll still have rules about understanding between crew members.  I think people are getting hung up that because a formalized procedure is no longer required they think there won't or can't be communication between those parties involved.

Jeff  

[tree68]

jeffhergert

  If red zone should go away, we'll still have rules about understanding between crew members.

The practice on some railroads was (and may still be) announcing that you're "going in."  If you're close enough for hand signals, this might be as simple as pointing in between the cars.  The actions by the engineer are the same.

We used to use a hand signal consisting of three fingers pointing up, answered by the engineer showing the same signal when three step was in place.  Cancelling three step was turning those three fingers down.

The FRA prefers the transaction be done over the radio now, so we do.

If the engineer was out of the seat, he should have at least put on three step protection, even to include pulling the reverser, and possibly turning off the isolation switch.  I would opine he should have held an on-the-air job briefing to the effect that he was going to be out of the seat, and possibly that three step was in place if needed.

The exception to that would be if another qualified employee (possibly the trainmaster) took over the seat.

[Convicted One]

243129

. Your statement elicited that response.

And this latest response is why I won't waste anymore of my time exchanging posts with you in the future.

[Euclid]

Overmod

 

Euclid

what if the employees chose to do their work without fouling the Amtrak track?  Should they still be required to have protection in order to work in the non-fouling space?

 

There are actually two questions here.  Obviously they have a 'right' to be anywhere on CSX property.  Whether it is advisable to 'encroach' on what might be considered the red zone of an immediately-adjacent railroad is a question, specifically, for CSX rules to address --

 

My only point is that if it is so obvious that the Amtrak area is so dangerous to CSX employees doing their job, then it should have been obvious to CSX.  And yet they did nothing to reduce the danger.  

 

[AnthonyV]

Euclid

 

 

My only point is that if it is so obvious that the Amtrak area is so dangerous to CSX employees doing their job, then it should have been obvious to CSX.  And yet they did nothing to reduce the danger.  

 

 

 

Bingo!  This is what I brought up a little while back.  They were put in a dangerous situation.  Clearly the locomotive was on CSX property and it was hit by flying ballast due to the high speed of the Amtrak trains.  Even if the conductors never entered Amtrak property, wouldn't they be hit by flying ballast?  I have no idea what that feels like but I can't imagine it feels good.

Again, I am speaking as a layman, but it seems to me they had no support from the engineer or CSX despite being put in a dangerous sitution.

Edit:  It seems like nobody had their back.

[BaltACD]

AnthonyV

 

Euclid 

My only point is that if it is so obvious that the Amtrak area is so dangerous to CSX employees doing their job, then it should have been obvious to CSX.  And yet they did nothing to reduce the danger.  

Bingo!  This is what I brought up a little while back.  They were put in a dangerous situation.  Clearly the locomotive was on CSX property and it was hit by flying ballast due to the high speed of the Amtrak trains.  Even if the conductors never entered Amtrak property, wouldn't they be hit by flying ballast?  I have no idea what that feels like but I can't imagine it feels good.

Again, I am speaking as a layman, but it seems to me they had no support from the engineer or CSX despite being put in a dangerous sitution.

Edit:  It seems like nobody had their back.

The employees - put themselves in the dangerous position.  They were not instructed or ordered by anyone to put themselves into the position to be struck by Amtrak.  Ground personnel notify the engineer of any actions the engineer needs to take with regard to movement of the train or not moving the train for the personnel on the ground to do what is necessary in the performance of their duties.  For the engineer to be a 'lookout' for the personnel on the ground, they would have to request that the engineer be a 'lookout.

Trains passing each other do not 'kick up' ballast.  Ballast striking the CSX locomotives would have been from the bodies of the CSX ground employees having been struck and in some manneer dislodging the ballast at the point of impace.  The air pressure differential between Amtrak and CSX trains as the Amtrak train passed would have knocked standing employees off their feet were the 'standing in the clear' between the passing trains and likely have 'rolled their bodies between the trains.  The only possible way for the employees to have survived had the recognized the approach of 175 was for them to lay prone in the 'center ditch' between the Amtrak and CSX tracks.  The did not recognize the approach of 175.

With Amtrak 175 coming around a curve just prior to where the Amtrak and CSX tracks parallell each other - it is unkonwn, an appearantly untested, if the CSX engineer could have seen the approach of Amtrak 175 in such a manner as to broadcast a warning to his ground crew.  

In the railroad enviornment, don't expect ANYONE to have your back, especially if you have not requested their assistance in having your back.  Employees are responsible for their actions, always have been, always will be.  The CSX ground employees did not exercise 'good judgement' in the actions they undertook and that lack of good judgement cost them their lives.

People who work in a office enviornment or a factory enviornment can't really comprehend the individual responsibility rail employees have when they are on the ground. 

There are 'Weed Weasels' but in real terms they are very few and very isolated in contact with crews - especially crews on 'high velocity' Main Line rail routes where 30 or more 'pool turns' are necessary to staff the traffic level.  Main Line efficiency testing is mostly concerned with signal compliance and speed compliance with Restricted Speed as well as the actions necessary to traverse at protected road crossing when that protections is not working or only partially working.

[Euclid]

BaltACD

The employees - put themselves in the dangerous position.  They were not instructed or ordered by anyone to put themselves into the position to be struck by Amtrak. 

Employees are responsible for their actions, always have been, always will be.  The CSX ground employees did not exercise 'good judgement' in the actions they undertook and that lack of good judgement cost them their lives.

Just to be clear, I agree with much of your comments that are included in your full post from which the above quote was extracted.  However, I don't agree with all of your comments which are rerepsented in the partial quote here.  In any case, you are partly responding to a quote of something I said, so I want to make it clear that I never advocated or expected that the engineer had any responsibility to protect the two conductors from danger.  I do, however, strongly feel that CSX did have such a responsibility. 

I do not agree that the accident was 100% the fault of the two conductors.  A failure of a company to maintain a safe workplace can cause an accident that kills or injures an employee that had no responsibility for the unsafe work place. 

You say the two conductors placed themselves in an unsafe place.  Yes, they alone moved into that location, but they were doing the work of their employer.  And even if their inspection work was finished and they could have walked on the other side, other employees may be required to inspect both sides of their train there in an area that everyone here agrees was too dangerous to enter without a formal arrangement to prevent Amtrak trains from passing that area. 

It is not clearly certain that the CSX conductors had any knowledge of the death trap along their mainline from trains other that those belonging to CSX.  It is not certain that they had any knowledge of the fact that protection was absolutely essential, nor had any knowledge of how to acquire protection.  It is also not clear whether protection would have been granted. 

The NTSB report itself clearly indicates that such protection was not readily available.   The whole point of their report was to request CSX and Amtrak to collaborate on an arrangement of communication and practice to make protection available for CSX employees when they are endangered by Amtrak trains.  They would not have recommended that be done if calling for protection was just a simple matter of asking for it, as some here have insisted.   In my opinion, CSX bears the majority if not the entirety of the responsibility for this fatal accident.  

[243129]

Euclid

I do not agree that the accident was 100% the fault of the two conductors. A failure of a company to maintain a safe workplace can cause an accident that kills or injures an employee that had no responsibility for the unsafe work place.

Vetting ,training, supervision.

Euclid

You say the two conductors placed themselves in an unsafe place. Yes, they alone moved into that location, but they were doing the work of their employer.

Vetting. They displayed no common sense.

Euclid

It is not clearly certain that the CSX conductors had any knowledge of the death trap along their mainline from trains other that those belonging to CSX. It is not certain that they had any knowledge of the fact that protection was absolutely essential, nor had any knowledge of how to acquire protection.

Training, supervision.

Euclid

In my opinion, CSX bears the majority if not the entirety of the responsibility for this fatal accident.

I go with majority.

 

Bottom line: Poor vetting, poor training, poor supervision.

[charlie hebdo]

No surprises there. 

[243129]

[quote user="charlie hebdo"]

No surprises there. 

 How about you give your thoughts on the issue?

[Convicted One]

Euclid

I do not agree that the accident was 100% the fault of the two conductors.  A failure of a company to maintain a safe workplace can cause an accident that kills or injures an employee that had no responsibility for the unsafe work place. 

It was 100% within the employee's control to avoid the accident, I think that issue is getting confused here with "responsibility".

The accident happened during work time performing work duties, adjacent to the employer's property. And the employer is a deep pocket. And there are several situational factors that could be considered contributory.

Anyone who believes that it is not a jury who will ultimately decide where responsibility falls,...is fooling themselves.

[charlie hebdo]

[quote user="243129"]

charlie hebdo

No surprises there. 

 How about you give your thoughts on the issue?

 

My thoughts are the same as they were long ago.  There were multiple factors (as in most events)  but the largest was the lack of acumen or common sense by a supposedly senior conductor in walking on a busy,  high-speed track. 

[243129]

[quote user="charlie hebdo"]

243129

 

 

charlie hebdo

No surprises there. 

 How about you give your thoughts on the issue?

 

 

 

 

My thoughts are the same as they were long ago.  There were multiple factors (as in most events)  but the largest was the lack of acumen or common sense by a supposedly senior conductor in walking on a busy,  high-speed track. 

 

So are mine. Acumen? Common sense? Wouldn't that be part of the vetting process when they're interviewed for the job?

[Euclid]

Another point that is confused in this discussion is the choice to actually foul the Amtrak track versus the choice to walk in the clear of that track, between it and the CSX train.  Either one is the death trap I refer to.  So the employees’ decision to walk on the Amtrak track is a bit of a red herring. 

Over and over, I must remind that we are talking about workplace area that is a death trap in the future and in the past, and not just that one night a couple years ago.   And as a death trap, it should be completely off limits if no protection is used; no matter whether people are fouling the Amtrak track or in the clear between that track and the CSX train. 

I have no basis to judge the vetting that the two conductors were expected to pass.  One point that may have been missed in this discussion is that the so-called trainee had two years of experience on the job at CSX.

If there is any lack of common sense, it is with CSX having a workplace containing a hidden death trap apparently without any warning of it to employees while expecting them to enter that trap in the normal course of their work.

Note that the engineer lamented the fact that he forgot to warn the two conductors about the Amtrak track.  That means he did not assume that the two victims would already know about that hazard. 

[zugmann]

charlie hebdo

No surprises there.

Ever get the feeling of deja vu?

[Overmod]

zugmann

Ever get the feeling of deja vu?

Over and over and over again.

I don't think we should mistake walking in a conservative 'red zone' for walking in the actual gauge, which is what Euclid seems to have worked around to equating in his thinking.  The argument for milliseconds of emergency braking 'maybe' allowing an increased chance for survival applies much more directly when only air-blast displacement or the odd bit of thrown debris is the primary risk.  It's so near 100% death for any contact that we may as well treat it as certainty.

The weird failure of judgment here is walking IN the gauge, not proximity to high-speed track.  Should we have advisory 'red zone' awareness warnings for 4' out on a 125mph main line?  Of course ... says this non-railroader.  But do you need a rule not to walk in someone else's gauge without looking?  I knew that answer when I was six, and didn't need careful job training to establish it.