BaltACD 243129 tree68 The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it. It is common and there is a procedure in place on Amtrak. CSX employees fouling Amtrak property are subject to Amtrak procedures and rules I would assume. You know what ASS U ME is! Don't assume.
243129 tree68 The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it. It is common and there is a procedure in place on Amtrak. CSX employees fouling Amtrak property are subject to Amtrak procedures and rules I would assume.
tree68 The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it.
It is common and there is a procedure in place on Amtrak. CSX employees fouling Amtrak property are subject to Amtrak procedures and rules I would assume.
You know what ASS U ME is! Don't assume.
Well then why don't you explain to me what CSX procedure is in this instance so I don't have to ASS U ME.
EuclidHow would those employees have gone about obtaining protection from Amtrak? Walk me through the process. From what I gather, protection was not required. The only option I can see for them was to refuse to do the inspection without having protection.
Through their dispatcher or with direct contact with the Amtrak dispatcher. Common sense would dictate that required inspection of both sides of the train, especially the side with 100+ MPH traffic, would require some sort of protection.
Never too old to have a happy childhood!
tree68The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it.
tree68 243129 Before occupying the six foot adjacent to the Amtrak mainline those employees should have obtained protection from Amtrak. They did not for whatever reason and it cost them their lives. Poor vetting, poor training and poor supervision coupled with the conductor's inexperience are the root causes for this tragedy. The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it.
243129 Before occupying the six foot adjacent to the Amtrak mainline those employees should have obtained protection from Amtrak. They did not for whatever reason and it cost them their lives. Poor vetting, poor training and poor supervision coupled with the conductor's inexperience are the root causes for this tragedy.
Before occupying the six foot adjacent to the Amtrak mainline those employees should have obtained protection from Amtrak. They did not for whatever reason and it cost them their lives. Poor vetting, poor training and poor supervision coupled with the conductor's inexperience are the root causes for this tragedy.
The question would be how often such an event occurs. If it's common, then some sort of procedure should be in place. If it's once in a blue moon or less, existing rules already cover it.
There appears to be about 4 ft. of space between the boundaries of the foul zone of the CSX and Amtrak tracks. Is it okay for employees to occupy that 4 ft. space without protection?
If protection is not needed for working in that 4 ft. space, how do existing rules apply to working in that space? Would existing rules prohibit working in that 4 ft. space because doing so would not be the safest course?
How would those employees have gone about obtaining protection from Amtrak? Walk me through the process. From what I gather, protection was not required. The only option I can see for them was to refuse to do the inspection without having protection.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
BaltACDOnce upon a time - a railroad rule book was about 3.5 x 7 inches and about 150 - 160 pages of rules that were written in simple, declaritive English. In the present day a single rule can run to 7 pages in a 8.5 x 11 inch pages, written in the finest of legalize 'gotcha' (meaning that no matter what you do, you have violated some element of the rule).
Can you show us an example of one of those 7-page rules?
charlie hebdoThere is research to support the idea that having two people makes it less likely that either one will act cautiously. Each thinks the other is keeping watch.
Euclid Convicted One Euclid I certainly don't think that the two victims made a "dumb mistake", as you call it. Just to remain abundantly clear, what I said was 'this was not just the dumb mistake of one non-observant person' That is a far cry from me identifying the two victim's error as a dumb mistake. The reason I chose the wording I did is because there seems to be a popular mindset here among some, that anyone who does not share their priorities and their POV, must be morons. And I, like you, think there is a little more than just a lapse of common sense involved here. Unlike you, however, I don't believe that we can ever hope to have a set of safety rules so comprehensive that accidents will become completey avoidable. Human nature will assure that you won't. Okay, I see exactly what you meant now that I look at it again. Really, what you meant was that it was not a dumb mistake at all. I'm sorry for misinterpreting you. I am glad that you see what I see in this being more than a simple loss of common sense or something like not paying enough attention in a way that they were negligent. In terms of better training, I see two possible solutions. One would be to put in that rule I suggested earlier requiring anyone on any track of a multiple track mainline to get clear of the track immediatley upon the appearance of any train on any of the tracks in that mainline set. At least that is something with a specific meaning that is enforceable. And in learning the rule, one will also learn the reason for it, which is to not get caught by the illusion of two trains sounding like one. The other solution would be to train the actual experience of the illusion. This experience will register the danger far more effectively than just an explanation of it. Maybe some form of simulated virtual reality could give the actual experience. Show how a cautious thought process can be underway, and suddenly be caught off guard by this illusion. Then teach the danger signs for this trap, so people can learn to arm themselves against it. I would not expect it to prevent every accident of this type. But I think it could prevent 95% of them. In fact, I believe that far more of the unique two train illusion accidents could be prevented than the more common daydreaming loss of situational awareness accidents. I don't know how any of those could be prevented.
Convicted One Euclid I certainly don't think that the two victims made a "dumb mistake", as you call it. Just to remain abundantly clear, what I said was 'this was not just the dumb mistake of one non-observant person' That is a far cry from me identifying the two victim's error as a dumb mistake. The reason I chose the wording I did is because there seems to be a popular mindset here among some, that anyone who does not share their priorities and their POV, must be morons. And I, like you, think there is a little more than just a lapse of common sense involved here. Unlike you, however, I don't believe that we can ever hope to have a set of safety rules so comprehensive that accidents will become completey avoidable. Human nature will assure that you won't.
Euclid I certainly don't think that the two victims made a "dumb mistake", as you call it.
Just to remain abundantly clear, what I said was 'this was not just the dumb mistake of one non-observant person'
That is a far cry from me identifying the two victim's error as a dumb mistake.
The reason I chose the wording I did is because there seems to be a popular mindset here among some, that anyone who does not share their priorities and their POV, must be morons. And I, like you, think there is a little more than just a lapse of common sense involved here.
Unlike you, however, I don't believe that we can ever hope to have a set of safety rules so comprehensive that accidents will become completey avoidable.
Human nature will assure that you won't.
Okay, I see exactly what you meant now that I look at it again. Really, what you meant was that it was not a dumb mistake at all. I'm sorry for misinterpreting you. I am glad that you see what I see in this being more than a simple loss of common sense or something like not paying enough attention in a way that they were negligent.
In terms of better training, I see two possible solutions. One would be to put in that rule I suggested earlier requiring anyone on any track of a multiple track mainline to get clear of the track immediatley upon the appearance of any train on any of the tracks in that mainline set. At least that is something with a specific meaning that is enforceable. And in learning the rule, one will also learn the reason for it, which is to not get caught by the illusion of two trains sounding like one.
The other solution would be to train the actual experience of the illusion. This experience will register the danger far more effectively than just an explanation of it. Maybe some form of simulated virtual reality could give the actual experience. Show how a cautious thought process can be underway, and suddenly be caught off guard by this illusion. Then teach the danger signs for this trap, so people can learn to arm themselves against it.
I would not expect it to prevent every accident of this type. But I think it could prevent 95% of them. In fact, I believe that far more of the unique two train illusion accidents could be prevented than the more common daydreaming loss of situational awareness accidents. I don't know how any of those could be prevented.
So - is this incident the ONLY TIME a B&O/CSX crew has ever inspected a train in this location under these circumstance and thus there is a 100% failure. Or since the B&O & PRR have been operating trains on these tracks at this location with this track alignment since 1907 without a prior fatality (as far as I can find in the internet available DOT and NTSB reports) is this a singluar 'man failure' incident that was totally within the control of those who were struck.
CSX from my observations through the course of my employment has applied the Euclid form of overkilling the obvious with every incident creating more and more lawyer derived rules that in many cases require another lawyer to adjudicate the actions and/or reactions of employees to any and ever situation that comes into question.
The employee is responsible for their own safety in the performace of their duties.
Once upon a time - a railroad rule book was about 3.5 x 7 inches and about 150 - 160 pages of rules that were written in simple, declaritive English. In the present day a single rule can run to 7 pages in a 8.5 x 11 inch pages, written in the finest of legalize 'gotcha' (meaning that no matter what you do, you have violated some element of the rule).
If you can't protect them, kill them with paper.
There is research to support the idea that having two people makes it less likely that either one will act cautiously. Each thinks the other is keeping watch.
EuclidI certainly don't think that the two victims made a "dumb mistake", as you call it.
Convicted One I just look at the impact, both time and money, that would have on the "other" railroad, and can't see it happening. Railroad A passes parallel to railroad B, and anytime railroad B has an issue that has employees walking their train, (in the vicinity of said parallel trackage) then railroad A has to curtail operations until railroad B gets it's problem solved? No one is going to be very enthusiastic about compliance here. I'd expect what will happen is that some new rule will get written that specifies allowable behavior for the crew on the ground, and threatens termination for non-compliance....and that will be the end of it. One interesting aspect that I don't think anyone has mentioned yet, is that this was not just the dumb mistake of one, non-observant person. Two human beings "failed" here, so the circumstances had to be sufficiently complex to evade the perception of two people present at the time. You'll never be able to eliminate all accidents, too many variables. All you can try to do is learn from each one and try to apply that knowledge going forward
I just look at the impact, both time and money, that would have on the "other" railroad, and can't see it happening.
Railroad A passes parallel to railroad B, and anytime railroad B has an issue that has employees walking their train, (in the vicinity of said parallel trackage) then railroad A has to curtail operations until railroad B gets it's problem solved? No one is going to be very enthusiastic about compliance here.
I'd expect what will happen is that some new rule will get written that specifies allowable behavior for the crew on the ground, and threatens termination for non-compliance....and that will be the end of it.
One interesting aspect that I don't think anyone has mentioned yet, is that this was not just the dumb mistake of one, non-observant person. Two human beings "failed" here, so the circumstances had to be sufficiently complex to evade the perception of two people present at the time. You'll never be able to eliminate all accidents, too many variables. All you can try to do is learn from each one and try to apply that knowledge going forward
I certainly don't think that the two victims made a "dumb mistake", as you call it. We only have a small snapshot of their behavior. They suddenly spotted #66 coming at them. During the remaining 10 seconds, their attention was fixated on that train. And during that 10 seconds, they became distracted and did not realise it. So they forgot to look back. For all we know, they had been turning to look back every 5 seconds during the prior part of their walk. They may not have even been fouling the track until they came the last few cars of their train which then shifted over to toward them in the crossover.
This interesting aspect that you mention is the one singular point I have been trying to make over and over. Two people failed and that does indicate something rather strange. That is the point. This is not simply loss of situational awareness. If anything is to be learned from this mistake, that should be it. This was caused by an illusion and not just the loss of situational awareness. In the 1880s Lehigh Valley accident that I mentioned, about 30 people simultaneously failed to see what was happening because of the same illusion that is part this type of complex circumstances invovled in two trains being perceived as one train.
Convicted One Euclid Another example would be fulfilling the recommendation of the NTSB, in this case, to provide formal protection for employees working on the ground in close proximity to live tracks. Just sincerely curious.
Euclid Another example would be fulfilling the recommendation of the NTSB, in this case, to provide formal protection for employees working on the ground in close proximity to live tracks.
Just sincerely curious.
By providing “formal protection,” I am referring to the official common practice of protection that prohibits trains from entering specific areas while they are being occupied by people working on the ground. This protection would have to be set up by communication between CSX and Amtrak so that interference between the passing of trains though areas occupied by people on the ground would be prohibited. Providing such protection was the recommendation of the NTSB in their accident report on the Ivy City disaster, which is quoted in blue:
Recommendation
As a result of its investigation, the National Transportation Safety Board makes the following new safety recommendation:
To CSX Transportation and the National Railroad Passenger Corporation:
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)
As I mentioned, I doubt that CSX and Amtrak will arrange such protection as recommended by the NTSB. If they don’t, then I suggest adding the rule and training that I have described in this thread.
243129 wrote the following post an hour ago:
"Obtain foul time"
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Please provide a little detail sufficient to explain what would be expected of the railroads (Amtrak in the Ivy City incident) NOT causing the fouling.
Convicted One Euclid Another example would be fulfilling the recommendation of the NTSB, in this case, to provide formal protection for employees working on the ground in close proximity to live tracks. Okay, exactly what kind of formal protection would you like to see as mandatory in all future instances that are remotely similar to the Ivy City incident? Just sincerely curious.
Okay, exactly what kind of formal protection would you like to see as mandatory in all future instances that are remotely similar to the Ivy City incident?
Obtain 'foul time.'
EuclidAnother example would be fulfilling the recommendation of the NTSB, in this case, to provide formal protection for employees working on the ground in close proximity to live tracks.
243129Because you step off one track on to another does not mean you are 'clear'. All tracks should be considered 'live'. Once again we have a case of poor training.
Again (and again) I say: Poor vetting, poor training, poor supervision and lack of experience.
AnthonyVWhat blows my mind is how it takes literally just a few seconds of inattention for the situation to deteriorate into a disaster.
There are situations where a very short lapse of attention can cause injury or death. Normally, these are recognized, and a higher level of protection is added by a specific rule or a safety guard feature.
There are general rules that sound so logical and reasonable, but are really just empty platitudes. They are catchy slogans that go in one ear and out the other while leaving the satisfaction of how true and wise they are. One example is the always cited, “When in doubt always take the safest course.” Why would anybody not want to take the safest course? Why would there be any doubt about it? The only doubt that could enter into the decision is the doubt as to which course is safer. And if you have doubt about that, compliance is impossible. Utter nonsense. What this rule really means is, “If anything goes wrong, it is your fault for not being perfect.” If this were all that is needed, we would not have blade guards on table saws or safety locks on guns.
No, you have to go deeper than the catch-all slogan and instill a more specific form of protection. What I notice here is a kind of stubborn resistance to the idea of just one more rule. Rules create resentment in some because they think they are smart enough to not require rules. Rules symbolized the repression of being ordered to do things. Maybe that is why people draw the line at adding just one more rule.
Yet the railroad industry loves rules because they realize how essential they are. But they too draw the line at any new rules that require spending money. One example would be the rules involved in converting link and pin couplers to automatic couplers. What about taking the “safest course?” Another example would be fulfilling the recommendation of the NTSB, in this case, to provide formal protection for employees working on the ground in close proximity to live tracks.
Of course that will never be implemented by CSX. So this leaves more training and additional rules as the only way to address this unique problem of multiple track mainlines. This starts with the recognition of the problem.
The problem that makes the loss of situational awareness hard to avoid is that with the loss of situational awareness, you also lose the awareness that you have lost it. A person can lose situational awareness by daydreaming.
However, what makes this two train scenario so especially dangerous is not just a matter of unconscious drifting into other unrelated thoughts. Instead, this scenario introduces an illusion that all is safe. So, this is not just the usual loss of situational awareness. This is situational awareness being removed by a deception. The deception is introduced by the situation itself rather than by idle daydreaming or fatigue. This is far more sinister than just a daydream interrupting situational awareness.
A person hearing two trains and believing they are hearing one train has not lost situational awareness. They have instead been tricked by an illusion. The false assurance of that illusion causes them to rely less on their other senses such as vision.
243129 charlie hebdo More vetting! More training! More training!! More vetting!! Rah!! rah!! sis boom bah! Bulldog, bulldog, bow wow wow...Eli Yale!! You left out quality supervision.
charlie hebdo More vetting! More training! More training!! More vetting!! Rah!! rah!! sis boom bah! Bulldog, bulldog, bow wow wow...Eli Yale!!
More vetting! More training!
More training!! More vetting!!
Rah!! rah!! sis boom bah!
Bulldog, bulldog, bow wow wow...Eli Yale!!
You left out quality supervision.
They're around for the post-mortems.
243129 BaltACD Conductor lost situational awareness and he and his trainee paid the ultimate price. All the vetting in the world does not ELIMINATE the loss of situational awareness, it may decrease the occurence but it will not ELIMINATE it So, pray tell what would be 100% effective in your estimation?
BaltACD Conductor lost situational awareness and he and his trainee paid the ultimate price. All the vetting in the world does not ELIMINATE the loss of situational awareness, it may decrease the occurence but it will not ELIMINATE it
So, pray tell what would be 100% effective in your estimation?
Eliminate humans - humans are failable beings, always have been, always will be.
What blows my mind is how it takes literally just a few seconds of inattention for the situation to deteriorate into a disaster.
The accident example I describe is very old, so I have no idea what training they had. But the point I think is significant is that here you have about 25-40 people all making precisely that same mistake at the same moment. It also has exactly the same elements of losing situational awareness obviously without anyone of them realizing that they have lost situational awareness. On the face of it, the probability of that many people all making the same set of mistakes at the same time seems highly improbable. So this ought to be a strong hint that there is something else going on with this type of accident.
As I mentioned earlier, I think training specifically for this type of two train distraction accident would be of immense value in preventing it. But it has been over 100 years, and nobody has yet come to that realization. The training must demonstrate the loss of situational awareness as a direct experience in the trainee. They have to be made to feel it, and if they are, they will get it and always recognize the warning signs that this type of distraction is likely to occur. Nobody will lose situational awareness while they are actively trying not to lose it.
Otherwise, if we continue with the same old platitudinous slogan repetitions of head on a swivel, always expect trains, and always take the safest course; this type of accident will go on taking lives. Managers must ask whether they really want to solve the problem; or do they just want a rule that makes sure it was the employee’s fault.
Euclid Here is one example of this type of accident: I have notes on a newspaper article I found that was published circa 1886. It focuses on the Lehigh Valley Railroad where a large group of track workers were engaged in their work on a double track mainline with a grade in mountainous territory. Suddenly a slow moving milk train appeared heading up the grade. It was making a lot of noise and it drew everyone’s attention. The crew leader blew his whistle and waved for all the workers to clear the milk train. They acknowledged by the whole group simultaneously stepping back to clear the milk train. They stepped back off of the track they were working on, and onto the other mainline track without looking to see if it was clear. At that moment one of the so-called, “Lightning Express Trains” was coming down the grade and moving fast. So as the gang stepped back out of the path of the milk train, they stepped directly into the path of the express train. I would have to look this up for more details, but I recall that something like 10-15 people were killed and many more were injured. The express train stopped, and the remainder of the gang ran toward its engine bent on revenge. The crew saw this developing, and they highballed to get away from the rioting track gang. All of the elements of this type of distraction accident were present in this Lehigh Valley disaster. There were two trains simultaneously converging on a group of people. The sound of the milk train got their attention first because it was the loudest sound. Once it got their attention, they failed to look at the other track to see if it was clear. They saw and heard only one train, no doubt believing that they were completely alert for trains.
Here is one example of this type of accident:
I have notes on a newspaper article I found that was published circa 1886. It focuses on the Lehigh Valley Railroad where a large group of track workers were engaged in their work on a double track mainline with a grade in mountainous territory. Suddenly a slow moving milk train appeared heading up the grade. It was making a lot of noise and it drew everyone’s attention. The crew leader blew his whistle and waved for all the workers to clear the milk train. They acknowledged by the whole group simultaneously stepping back to clear the milk train. They stepped back off of the track they were working on, and onto the other mainline track without looking to see if it was clear.
At that moment one of the so-called, “Lightning Express Trains” was coming down the grade and moving fast. So as the gang stepped back out of the path of the milk train, they stepped directly into the path of the express train. I would have to look this up for more details, but I recall that something like 10-15 people were killed and many more were injured. The express train stopped, and the remainder of the gang ran toward its engine bent on revenge. The crew saw this developing, and they highballed to get away from the rioting track gang.
All of the elements of this type of distraction accident were present in this Lehigh Valley disaster. There were two trains simultaneously converging on a group of people. The sound of the milk train got their attention first because it was the loudest sound. Once it got their attention, they failed to look at the other track to see if it was clear. They saw and heard only one train, no doubt believing that they were completely alert for trains.
Because you step off one track on to another does not mean you are 'clear'. All tracks should be considered 'live'. Once again we have a case of poor training.
BaltACDConductor lost situational awareness and he and his trainee paid the ultimate price. All the vetting in the world does not ELIMINATE the loss of situational awareness, it may decrease the occurence but it will not ELIMINATE it
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