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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by tree68 on Friday, June 28, 2019 9:36 AM

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.  

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Posted by 243129 on Friday, June 28, 2019 9:32 AM

tree68

 

 
243129
They were trained and supervised inadequately, they were inexperienced and exhibited zero common sense and it cost them their lives. CSX bears a portion of the blame also.

 

In that respect only, I'll agree that CSX gets part of the blame.  

 

You do not think they were trained and supervised inadequately or that they were inexperienced?

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Posted by Euclid on Friday, June 28, 2019 9:18 AM

tree68
 
Euclid
Is it accurate to conclude that this statement by the NTSB means that the operating crews were not prohibited from walking either on or near the Amtrak tracks without protection?

 

No.

 

Only that operating crews were not prohibited from walking either on or near the Amtrak tracks.

 

Why do you assume that the NTSB statement also includes the condition that protection was required in order for their statement to be true. They did not say that. 

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

 

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Posted by tree68 on Friday, June 28, 2019 9:02 AM

243129
They were trained and supervised inadequately, they were inexperienced and exhibited zero common sense and it cost them their lives. CSX bears a portion of the blame also.

In that respect only, I'll agree that CSX gets part of the blame.  

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Posted by tree68 on Friday, June 28, 2019 9:00 AM

Euclid
Is it accurate to conclude that this statement by the NTSB means that the operating crews were not prohibited from walking either on or near the Amtrak tracks without protection?

No.

Only that operating crews were not prohibited from walking either on or near the Amtrak tracks.

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Posted by Euclid on Friday, June 28, 2019 8:46 AM

Euclid

From the report:

What does this mean?

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

Is it accurate to conclude that this statement by the NTSB means that the operating crews were not prohibited from walking either on or near the Amtrak tracks without protection?

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Posted by 243129 on Friday, June 28, 2019 8:05 AM

tree68

Additionally, I would opine that there was no rule or other directive in place because up until now, none was needed.  Crews abided by the existing rules and that was sufficient.

 

They were trained and supervised inadequately, they were inexperienced and exhibited zero common sense and it cost them their lives. CSX bears a portion of the blame also.

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Posted by tree68 on Friday, June 28, 2019 7:48 AM

Additionally, I would opine that there was no rule or other directive in place because up until now, none was needed.  Crews abided by the existing rules and that was sufficient.

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Posted by BaltACD on Friday, June 28, 2019 7:29 AM

tree68
 
Euclid

From the report:

What does this mean?

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

That there was no rule or other directive stating that the operating crews were not to walk on the Amtrak ROW.

On the other hand, there's nothing that says they are required to, either.  Prudence would dictate that they did not, or if they did, that they would exercise due regard toward the possibility of traffic, in either direction (which is a rule).

Just because you can do something doesn't mean you have to...

To the individual - EVERY RULE is optional - following or violating rules have consequences.

Piling rule upon rule for a individual that, for whatever the reason, is not going to comply with the base rule is a waste of paper and ink (or bits, bytes and storage space).

In this incident, the most elemental of rules was not complied with - the safe course was not taken. 

 

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Posted by 243129 on Thursday, June 27, 2019 9:35 PM

Lithonia Operator

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

 

"Stuff" like what? Please elaborate.

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Posted by tree68 on Thursday, June 27, 2019 9:34 PM

Euclid

From the report:

What does this mean?

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

That there was no rule or other directive stating that the operating crews were not to walk on the Amtrak ROW.

On the other hand, there's nothing that says they are required to, either.  Prudence would dictate that they did not, or if they did, that they would exercise due regard toward the possibility of traffic, in either direction (which is a rule).

Just because you can do something doesn't mean you have to...

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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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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 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 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 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 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 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 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 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 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 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 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.

LarryWhistling
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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 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 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 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 7:10 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 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 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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