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CSX Fatalities Probable Cause, Ivy City, DC

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

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

It's really that simple.

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

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

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

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

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

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

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

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

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

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

 

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

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

It's really that simple.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bow

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

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

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

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

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

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

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

 

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

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

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

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

It's really that simple.

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

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

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

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

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

 

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

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

 

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Posted by Euclid on Wednesday, June 26, 2019 4:30 PM

tree68
 
Euclid
...it would not have been necessary if they had stayed off that track. 

 

That's all you really need to say.  Case closed.

 

Oh but you took what I said out of context in order to make it match what you have been saying.  That is a funny trick.

And you did not answer my question.

Here is what I said with the portion you extracted in blue:

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

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Posted by BaltACD on Wednesday, June 26, 2019 4:26 PM

Overmod
 
BaltACD
I guess Euclid won't be happy unless when you break one rule you have now broken 10 or 20. 

The problem being that no matter how many rules you have, people ignoring them will still slip through the cracks ... or the rules you can remember aren't the things that would keep you alive.

I'm tempted to remember Mr. Salk's vaccine ... he had the equivalent of 100 rules or more, and still children died.  What we need is an approach closer to Sabin's: what can effectively overcome any effects of inattention (or poor attitude, etc.) under any circumstance? -- formalize and teach that so people are mindful when necessary.

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

Think of it as robots - not humans with functioning brain waves.  Think of brain waves as being similar to ocean waves - and we now have documentation that ocean waves occasionally generate 'rogue' waves - waves capable of sinking a vessel and not leaving a trace that it ever existed.  Even the 'best' of real live humans are subject to that 'ah sh.t moment' - the thing that they KNEW better than doing but did it anyway for a unknown and uncharted reason.  The human animal will never be a successful robot with 100% robotic efficiency.

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Posted by Overmod on Wednesday, June 26, 2019 3:26 PM

BaltACD
I guess Euclid won't be happy unless when you break one rule you have now broken 10 or 20.

The problem being that no matter how many rules you have, people ignoring them will still slip through the cracks ... or the rules you can remember aren't the things that would keep you alive.

I'm tempted to remember Mr. Salk's vaccine ... he had the equivalent of 100 rules or more, and still children died.  What we need is an approach closer to Sabin's: what can effectively overcome any effects of inattention (or poor attitude, etc.) under any circumstance? -- formalize and teach that so people are mindful when necessary.

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

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Posted by tree68 on Wednesday, June 26, 2019 2:35 PM

Euclid
...it would not have been necessary if they had stayed off that track. 

That's all you really need to say.  Case closed.

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Posted by BaltACD on Wednesday, June 26, 2019 2:35 PM

Euclid
 
tree68 
Euclid
The safe course is mandatory protection.  It probably would have saved the lives of the two victims in this accident.  What's wrong with that?  People make mistakes.  We provide backup safety measures.  Sometimes they save people from injury or death.  

Had the rule been in place (and if they had been inclined to complied with it), I would opine that they would have crossed over to the other side of their consist rather than deal with the hassle of requesting and receiving foul time.

Had they crossed over in the first place, we wouldn't be having this discussion.

They didn't need to be walking on 95 MPH active rails.  Even with existing rules, it was not the safe course.

I have no problem with the suggested rule, but it really wasn't necessary here. 

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

Isn't a redundancy in rules worth it if it saves a life that would have been lost without the redundancy?  

Rules at present have reached the level of redundently redundant redundancy - break one rule and you have broken 3 to 5 or more.  I guess Euclid won't be happy unless when you break one rule you have now broken 10 or 20.

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Posted by Euclid on Wednesday, June 26, 2019 2:30 PM

tree68
 
Euclid
The safe course is mandatory protection.  It probably would have saved the lives of the two victims in this accident.  What's wrong with that?  People make mistakes.  We provide backup safety measures.  Sometimes they save people from injury or death.   

 

Had the rule been in place (and if they had been inclined to complied with it), I would opine that they would have crossed over to the other side of their consist rather than deal with the hassle of requesting and receiving foul time.

Had they crossed over in the first place, we wouldn't be having this discussion.

They didn't need to be walking on 95 MPH active rails.  Even with existing rules, it was not the safe course.

I have no problem with the suggested rule, but it really wasn't necessary here.

 

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

Isn't a redundancy in rules worth it if it saves a life that would have been lost without the redundancy?  

If the new rule was necessary to save their lives, wouldn't it have been necessary in this incident?

Wouldn't the addition of the new rule be a safer course that the current status without the new rule?

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Posted by tree68 on Wednesday, June 26, 2019 1:46 PM

Euclid
The safe course is mandatory protection.  It probably would have saved the lives of the two victims in this accident.  What's wrong with that?  People make mistakes.  We provide backup safety measures.  Sometimes they save people from injury or death.   

Had the rule been in place (and if they had been inclined to complied with it), I would opine that they would have crossed over to the other side of their consist rather than deal with the hassle of requesting and receiving foul time.

Had they crossed over in the first place, we wouldn't be having this discussion.

They didn't need to be walking on 95 MPH active rails.  Even with existing rules, it was not the safe course.

I have no problem with the suggested rule, but it really wasn't necessary here.

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Posted by Euclid on Wednesday, June 26, 2019 1:25 PM

tree68
 
Euclid
Better communication could be used to protect employees who find it necessary to occupy another railroad’s active tracks.

 

The question here being whether it was necessary to occupy another railroad's active tracks, or merely expedient.

Even their own engineer questioned why they were where they were.

I have no problem with NTSB's suggested rule, but in this case, it really wasn't necessary, had the crew exercised reasonable caution and taken the safe course.

 

The safe course is mandatory protection.  It probably would have saved the lives of the two victims in this accident.  What's wrong with that?  People make mistakes.  We provide backup safety measures.  Sometimes they save people from injury or death.   

 

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Posted by tree68 on Wednesday, June 26, 2019 1:05 PM

Euclid
Better communication could be used to protect employees who find it necessary to occupy another railroad’s active tracks.

The question here being whether it was necessary to occupy another railroad's active tracks, or merely expedient.

Even their own engineer questioned why they were where they were.

I have no problem with NTSB's suggested rule, but in this case, it really wasn't necessary, had the crew exercised reasonable caution and taken the safe course.

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Posted by Overmod on Wednesday, June 26, 2019 12:40 PM

243129
This is why I mention poor vetting and poor supervision.

And this is right, but neither is going to change things 'as they have become'.

We're not going to evolve any kind of cadre of CSX management to exercise 'vetting' oversight even in an era where the people interested in T&E have the 'right stuff' by classical standards.  (The situation is much worse at Amtrak, I suspect, where politically correct thinking seems to be guiding some of the hiring policy, but that is not really relevant here.)

Likewise no amount of 'supervision', again by CSX management personnel, would likely have assisted here (other than by instilling something like a drone- and weed-weasel enforced state of general fear, which certainly seems to be the 'approach' taken by a number of railroads!)

This has to go back to what you were really calling for at the outset: basically a self-policing by the unions and similar organizations to perform some of the appropriate 'vetting', and all the appropriate training and perhaps mutual 'supervision', to keep all the brothers and sisters mutually safe.  All the time, not just when company rules 'make' them so.

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Posted by Euclid on Wednesday, June 26, 2019 12:37 PM

There are lots of cases where adding more rules or replacing existing rules with better rules will make accidents less likely. To say that if someone gets killed by disobeying a rule, nothing more in the way of accident prevention could have prevented the accident is nonsense. People are told to keep their fingers out of table saws, and then we put guards on them.  But we all know that no stinking’ guard would have prevented a person from putting their fingers into the saw, since they went ahead and put them in there while knowing not to.  Nonsense. 

Also, in this case, there was no rule that prohibited being on Amtrak track within the foul zone.  So a new rule would not be an addition to an existing rule which is considered to be all that is necessary. 

In this thread, we have learned that asking for protection was not required, but was somehow the right thing to do. We have also learned that no additional rules would have helped prevent death or injury in this accident or in future accidents because this accident was 100% caused by the victims, who failed to use all means necessary to prevent the accident.  And if people fail to do that, nothing more can be done to make them safer.  Therefore, no additional rules can be of any benefit.   

Essentially, with NTSB’s official recommendation they call for the current protection, which is available to employees as an option if they ask for it, to be converted to being mandatory under conditions such as those in this Ivy City accident.  This would be a new rule made for the purpose of preventing accidents and saving lives. 

In a letter to Amtrak, the NTSB communicates their official recommendation in their report with a little added information:

The NTSB identified the following safety issue: • Better communication could be used to protect employees who find it necessary to occupy another railroad’s active tracks. Accordingly, the NTSB makes the following safety recommendation to Amtrak. Additional information regarding this recommendation can be found in the noted section of the report. • Prohibit employees from fouling adjacent tracks of another railroad unless the employees are provided protection from trains and/or equipment on the adjacent tracks by means of communication between the two railroads. (R-19-006) (See Safety Issue section) The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives.

 

Note that the NTSB is vitally interested in this addition of a rule, which would make protection mandatory because it will prevent accidents and save lives.

 

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Posted by 243129 on Wednesday, June 26, 2019 12:21 PM

Overmod

 

 
Euclid
I am saying that it is so extra dangerous, that special rules and training are needed more than ever.

 

I know, but note that I think Balt is right: no amount of 'rules' or 'training' provided by CSX will have any meaningful effect on actually resolving the issues that led to these deaths.  

There may be a parallel with the situation that led to the open switch at Cayce.  All the 'rules' in the world didn't get those two to close that switch, specifically including the wacky government procedural 'safety' requirements.  The only thing you'd likely produce with more and more putting-out-fires rules is more attitude problems and more distraction of foreground attention and the like.

 

This is why I mention poor vetting and poor supervision.

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Posted by Overmod on Wednesday, June 26, 2019 12:16 PM

Euclid
I am saying that it is so extra dangerous, that special rules and training are needed more than ever.

I know, but note that I think Balt is right: no amount of 'rules' or 'training' provided by CSX will have any meaningful effect on actually resolving the issues that led to these deaths.  

There may be a parallel with the situation that led to the open switch at Cayce.  All the 'rules' in the world didn't get those two to close that switch, specifically including the wacky government procedural 'safety' requirements.  The only thing you'd likely produce with more and more putting-out-fires rules is more attitude problems and more distraction of foreground attention and the like.

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Posted by BaltACD on Wednesday, June 26, 2019 12:10 PM

You can lead a horse to water - but you can't force them to drink.

You can train employees on safety.  You can paper them in Safety Rules - but you can't force them to observe them - when you are not they to observe their actions and question their thought process.

The death of these employees, unfortunately, fall squarely on their own shoulders and thought processes.

Writing more rules and procedures for them to discount and fail to comply with is a continuing exercise in ultimate futility.

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Posted by Euclid on Wednesday, June 26, 2019 11:57 AM

Overmod
 
Euclid
The factor that most prevents this type of accident is NOT wariness, caution, alertness, and expecting trains.  What most prevents it is the rarity of the coincidence of two trains converging on a person at the same moment.  In other words, it strikes by chance rather than by carelessness.

 

In my opinion ... and it's just one person's opinion ... that could not be more wrong in terms of evolving any kind of policy going forward.

Don't get me wrong.  I am not suggesting that the cause is only a matter of the fate of train coincidence.  But that coincidence is required for this to occur.  My point is that the rarity of that coincidence does more to prevent this type of accident than the normal safety precautions, even though they are also essential. 

So what I am saying is that this type of distraction includes an unusual illusion that is much more likely to disarm normal protective wariness than the more usual distraction that does not involve the simultaneous apprach of two trains. 

So the saving grace (if it can be called that) is that necessary circumstance of two train coincidence is relatively rare. 

But I am not saying that safety training for this type of accident is pointless because it is just caused by fate.  I am saying that it is so extra dangerous, that special rules and training are needed more than ever.

 

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Posted by tree68 on Wednesday, June 26, 2019 11:18 AM

Overmod
It happens that in this particular CIRCUMSTANCE there was a confusion of train approach, due in part to the horn and light confusion.  But that remains only circumstantial: the issue of why the two of them were walking in the gauge of a railroad that didn't 'belong to them' in the first place is a much more relevant one.  And addressing the factors that 'put' them there, doing what they were doing or not doing, is where the focus on our 'response' has to be.

Chalking this up to dreadful coincidence is fine.  I have agreed that some sort of simulator could be built to experience the effect of 'multipath' directly, to give what I think is the full effect of 'direct experience of the deception'.  But it is surely more important to train people how to stay out of the damn gauge in the first place, or to demand and wait to receive full protection (and take any consequences of that decision) if they even feel the want to.

This.  Emphasis mine.

The confusion regarding the two trains would not have been a factor if they'd stayed off the track in the first place.

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Posted by Overmod on Wednesday, June 26, 2019 11:13 AM

Euclid
The factor that most prevents this type of accident is NOT wariness, caution, alertness, and expecting trains.  What most prevents it is the rarity of the coincidence of two trains converging on a person at the same moment.  In other words, it strikes by chance rather than by carelessness.

In my opinion ... and it's just one person's opinion ... that could not be more wrong in terms of evolving any kind of policy going forward.

It happens that in this particular CIRCUMSTANCE there was a confusion of train approach, due in part to the horn and light confusion.  But that remains only circumstantial: the issue of why the two of them were walking in the gauge of a railroad that didn't 'belong to them' in the first place is a much more relevant one.  And addressing the factors that 'put' them there, doing what they were doing or not doing, is where the focus on our 'response' has to be.

Chalking this up to dreadful coincidence is fine.  I have agreed that some sort of simulator could be built to experience the effect of 'multipath' directly, to give what I think is the full effect of 'direct experience of the deception'.  But it is surely more important to train people how to stay out of the damn gauge in the first place, or to demand and wait to receive full protection (and take any consequences of that decision) if they even feel the want to.

To put this in a little context: I visited Enola circa 1975, about the time the first Amfleet shells were being built at Red Lion.  Crossing the ready tracks to the engine house was the first time I'd ever experienced not being ready to miss all the moving trains safely ... even with my head on a swivel, carefully staying 10' or more from anything standing, I still had one person have to 'plug' a light GG1 to miss me.  Trained railroaders evidently did not have this problem, but it was not for exercising less than 'total' attention when in harm's way ... any time in harm's way.  The big training issue, perhaps, is that anytime you see a distraction that can't hurt you -- start making a conscious effort to watch for something that can.  That one thing alone will likely save lives in any confusing combination of circumstances.

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Posted by 243129 on Wednesday, June 26, 2019 10:47 AM

charlie hebdo
Overmod: I think you brought up some very pertinent questions and observations. Given his background, a lack of vetting or training seem minor factors for the senior conductor.

"Minor factors"?  It cost them their lives. Clearly this 'senior' conductor did not posseess the acumen for railroad operations. Why would he choose to return to the head end via a live track on a foreign railroad when the option of returning on a safe track on his own railroad was available? Why were they both not vigilant for traffic in either direction? Inexperience, poor vetting and poor training along with poor supervision( there was a trainmaster on scene) is why. Again we have the unknowing 'instructing' the unknowing and supervised by the unknowing. Dupont, Frankford Jct., Cayce SC etc. , see a pattern here?

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Posted by Euclid on Wednesday, June 26, 2019 10:46 AM

Overmod
We're tacitly insulting the dead by saying the senior conductor -- who came from a railroad family and almost certainly knew to 'expect a train on any track at any time' by the time he was weaned -- somehow mistrained his Padawan learner into lethal ignorance ... and yet, there they were, and didn't even look around before the moment of collision. We need to look carefully into what the probable reasons for that might be, and what strategies and approaches might best prevent 'this sort of thing' from happening again.

Yes, I absolutely agree.  This detail that you cite (in red) is my only concern and focus of interest in this thread and earlier threads on this accident.  Long before this accident, I had given a great deal of thought to just this specific type of accident which involves hearing two trains sounding as one, having attention locked to the first one seen, and getting struck by the second one.  The Ivy City accident is a textbook example.  I know of several accounts of this type of accident, and if thorough research were done, I expect that accounts of it happening would be a thousand or more. 

This is a unique form of distraction that goes way beyond simple distraction from daydreaming, conversations with others, or stress from other events.  Those things merely pull you off your concentration on the moment. With this two-train scenario, I see the type of distraction involved as being an illusion or deception that can kill even those who are completely focused on the task at hand such as expecting and watching for trains, and being alert to that purpose.

I am also convinced that the gravity of this hazard cannot be explained in words sufficiently for it to register in the listener.  However, it has been identified as the cause of specific accidents including this one, for which the NTSB has identified it and explained it perfectly.  And yet, I think nobody will understand it well enough to grasp the gravity of it.

Everyone is fallible to some extent, and this particular railroad hazard stands out as being the most capable of defeating a person’s defenses.  The factor that most prevents this type of accident is NOT wariness, caution, alertness, and expecting trains.  What most prevents it is the rarity of the coincidence of two trains converging on a person at the same moment.  In other words, it strikes by chance rather than by carelessness.    

The only way a people can hope to protect themselves from this is to understand it in the deepest terms.  The only way they can do that is to come face to face with it in direct experience.  Then they will realize the terror of just how deceptively pernicious this really is.  This is what should be trained, and done so by direct experience of the deception.  It would make the point.

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