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CSX Fatalities Probable Cause, Ivy City, DC

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Posted by tree68 on Monday, June 17, 2019 11:21 PM

Euclid
The two conductors were sent to inspect their train by CSX.  If they needed protection they should not have had to ask for it.  It should have been provided by CSX.

You're assuming that the dispatcher is intimately familiar with that location AND knew that the crew members were going to foul the Amtrak track.  That's a real reach.  

Euclid
The NTSB said there was no prohibition against the two conductors fouling a live track.

But there are rules in place regarding what the crew is supposed to do if they are fouling a live track.
Euclid
 There is no indication that the employees were required to seek permission to be on the Amtrak track while doing their job.
 See my previous post.  
Euclid
If they needed permission, then CSX should have obtained if for them.
And the dispatcher likely would have, had the crew requested it.  
Euclid
CSX knew where the company's train was standing during the inspection.  They should have known that location required protection for the two employees. 

Again, you're assuming that the dispatcher knows that specific locale intimately, AND that the dispatcher knew the crew decided to foul Amtrak's rail.  I don't recall where the dispatcher was at the time - that's about the period when all CSX dispatchers were being relocated to Jacksonville.

BaltACD
To my knowledge - those rules are taught to MofW personnel, not T&E personnel.  Not saying that it shouldn't be taught to T&E - just that it is not.

There's nothing in the rule or any surrounding text that indicates it's for MOW only.   Regardless, operating personnel would need to be aware of the rule so they can comply from their standpoint.   And Rule V (vee) clearly applies to ALL personnel.

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Posted by BaltACD on Monday, June 17, 2019 11:13 PM

tree68
NORAC already has a rule in place that would apply in this situation:

V. Fouling Tracks Fouling a track may be necessary in the performance of railroad work. Employees must expect the movement of trains, locomotives, or other on-track equipment at any time, on any track, in either direction. Employees must maintain a vigilant lookout for and detect the approach of a train, locomotive or other railroad equipment moving in either direction. Proper safeguards for the job classification needing protection must be in place before fouling any track.

Direct copy and paste from NORAC, 11th Edition.

I have no reason to doubt that CSX has the same, or a very similar, rule.  Amtrak uses NORAC.

In addition, there are specific rules about fouling track:

140. Foul Time Foul Time may be issued only by the Dispatcher.

A. Action Required Prior to Issuance Before issuing or authorizing Foul Time, the Dispatcher must determine that no trains or other on-track equipment have been authorized to occupy the track segment to be fouled. In signaled territory, the Dispatcher must ensure that Stop Signals have been displayed and blocking devices applied to controls of switches and signals leading to the affected track. When trains are to be held at a TBS where blocking devices cannot be applied, the Dispatcher must issue Form D line 13 instructing the Operator to hold trains clear of the affected track.

B. Permission to Foul Permission to foul the track must include the following information:

1. Title and name of employee receiving foul time

2. Track designation

3. Track limits (between/at)

4. Time limits

The receiving employee must repeat this permission and the Dispatcher must then confirm it before the Foul Time becomes effective.

 C. Releasing Foul Time Once protection has been provided, it must be maintained until the employee who was granted the foul time has released the foul time. The employee who was granted Foul Time must not release the Foul Time until they have ensured that all fouling activity under their authority has been cleared. The release must include the employee's title and name, and the track designation and limits being released. This information must be repeated by the Dispatcher, and confirmed by the employee releasing the foul time before blocking devices are removed.

NORAC 11th Edition – February 1, 2018 

To my knowledge - those rules are taught to MofW personnel, not T&E personnel.  Not saying that it shouldn't be taught to T&E - just that it is not.

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Posted by tree68 on Monday, June 17, 2019 11:03 PM

NORAC already has a rule in place that would apply in this situation:

V. Fouling Tracks Fouling a track may be necessary in the performance of railroad work. Employees must expect the movement of trains, locomotives, or other on-track equipment at any time, on any track, in either direction. Employees must maintain a vigilant lookout for and detect the approach of a train, locomotive or other railroad equipment moving in either direction. Proper safeguards for the job classification needing protection must be in place before fouling any track.

Direct copy and paste from NORAC, 11th Edition.

I have no reason to doubt that CSX has the same, or a very similar, rule.  Amtrak uses NORAC.

In addition, there are specific rules about fouling track:

140. Foul Time Foul Time may be issued only by the Dispatcher.

A. Action Required Prior to Issuance Before issuing or authorizing Foul Time, the Dispatcher must determine that no trains or other on-track equipment have been authorized to occupy the track segment to be fouled. In signaled territory, the Dispatcher must ensure that Stop Signals have been displayed and blocking devices applied to controls of switches and signals leading to the affected track. When trains are to be held at a TBS where blocking devices cannot be applied, the Dispatcher must issue Form D line 13 instructing the Operator to hold trains clear of the affected track.

B. Permission to Foul Permission to foul the track must include the following information:

1. Title and name of employee receiving foul time

2. Track designation

3. Track limits (between/at)

4. Time limits

The receiving employee must repeat this permission and the Dispatcher must then confirm it before the Foul Time becomes effective.

 C. Releasing Foul Time Once protection has been provided, it must be maintained until the employee who was granted the foul time has released the foul time. The employee who was granted Foul Time must not release the Foul Time until they have ensured that all fouling activity under their authority has been cleared. The release must include the employee's title and name, and the track designation and limits being released. This information must be repeated by the Dispatcher, and confirmed by the employee releasing the foul time before blocking devices are removed.

NORAC 11th Edition – February 1, 2018 

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Posted by Euclid on Monday, June 17, 2019 9:24 PM

tree68
 
243129
Then this means of contact should have been used to obtain protection.

 

Coulda, shoulda, woulda.

The crew members fouled another railroad's track without asking permission, for protection, or anything else.  Further, they neglected to maintain situational awareness under those circumstances.  That is completely on them, rest their souls.

CSX's BC dispatcher didn't know they were fouling the Amtrak line, so could not know they needed protection and did not seek it.

Amtrak's K Tower didn't know they were fouling the Amtrak line, so could not know they needed protection and did not provide it.

There were already rules in place to prevent this incident.  New rules only provide new avenues to break the rules.

 

The two conductors were sent to inspect their train by CSX.  If they needed protection they should not have had to ask for it.  It should have been provided by CSX.

The NTSB said there was no prohibition against the two conductors fouling a live track. 

There is no indication that the emplyees were required to seek permission to be on the Amtrak track while doing their job.  If they needed permission, then CSX should have obtained if for them. 

CSX knew where the company's train was standing during the inspection.  They should have known that location required protection for the two employees. 

The fact that new rules provide new opportunities to break rules seem like a mighty lame excuse to not have all the rules that are necessary.

The rule I suggested would have saved their lives.  It is a very logical rule since it directly defeats the hazard of two trains converging on people simultaneoulsy.  I can't imagine why such an obvious rule was not in place a century ago.   

I am not conviced that there were rules in place to prevent this accident.  Rule 10 does not address how to maintain situational awareness while walking along a track.  This is the rule they need:

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group. 

 

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Posted by 243129 on Monday, June 17, 2019 8:53 PM

tree68
The crew members fouled another railroad's track without asking permission, for protection, or anything else. Further, they neglected to maintain situational awareness under those circumstances. That is completely on them, rest their souls.

As I stated previously: Poor vetting, poor training, poor supervision.

tree68
CSX's BC dispatcher didn't know they were fouling the Amtrak line, so could not know they needed protection and did not seek it.

Another poster, who purports to know, stated that CSX rules require you to inspect both sides of the train in this situation so the BC dispatcher should have known that they required protection and sought it.

 

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Posted by tree68 on Monday, June 17, 2019 8:43 PM

243129
Then this means of contact should have been used to obtain protection.

Coulda, shoulda, woulda.

The crew members fouled another railroad's track without asking permission, for protection, or anything else.  Further, they neglected to maintain situational awareness under those circumstances.  That is completely on them, rest their souls.

CSX's BC dispatcher didn't know they were fouling the Amtrak line, so could not know they needed protection and did not seek it.

Amtrak's K Tower didn't know they were fouling the Amtrak line, so could not know they needed protection and did not provide it.

There were already rules in place to prevent this incident.  New rules only provide new avenues to break the rules.

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Posted by 243129 on Monday, June 17, 2019 8:21 PM

BaltACD
The direct communication between the BC Dispatcher and Amtrak's Operator at K Tower has been the normal means of contact.

Then this means of contact should have been used to obtain protection.

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Posted by Euclid on Monday, June 17, 2019 8:00 PM

Miningman

Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

 

I agree that working without protection in this circumstance seems unbelievably risky for an industry that always pushes safety. 

CSX had the option of providing protection by arranging it through Amtrak for the two conductors while working along their train.  Also, the two conductors had the option of asking for protection.  CSX had the option providing protection according to their request or turning them down.  The two conductors had the option of refusing to do the work without protection, and the CSX may have then reacted by granted the protection or refusing it.  They also had the option of disciplining the two conductors for refusing to work without protection.  It is unclear how much time it would have taken to set up such protection.

The point is that nobody was required to provide protection, and nobody asked for it.  What the NTSB wants is such protection made mandatory and a rule forbidding working without protection in cases such as this one at Ivy City.

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Posted by BaltACD on Monday, June 17, 2019 7:47 PM

243129
 
BaltACD
To my recollection, there is no direct phone line between the CSX BC Train Dispatcher and whatever desk Amtrak's Dispatcher for the territory inhabits. 

I find that hard to believe given the proximity of the CSX and Amtrak main lines.

Hard to believe of not - there isn't.  The direct communication between the BC Dispatcher and Amtrak's Operator at K Tower has been the normal means of contact.

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Posted by 243129 on Monday, June 17, 2019 7:45 PM

BaltACD
To my recollection, there is no direct phone line between the CSX BC Train Dispatcher and whatever desk Amtrak's Dispatcher for the territory inhabits.

I find that hard to believe given the proximity of the CSX and Amtrak main lines.

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Posted by BaltACD on Monday, June 17, 2019 7:39 PM

Miningman
Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

However, that is not a procedure that was outlined in TTSI for the Capital Subdivision.  There is also no indication of what radio channel is the Amtrak Road Channel in the area, for crews to be able to break in on (I believe there are approximately 100 FRA designated radio channels that railroad radios can be tuned - the channels for a territory are listed in the TTSI).  To my recollection, there is no direct phone line between the CSX BC Train Dispatcher and whatever desk Amtrak's Dispatcher for the territory inhabits.  The BC Train Dispatcher does have a direct line to DC Metro's 'dispatching' center for the line West of QN Tower on the Metropolitan Subdivision where Metro's tracks are in a fenced off area BETWEEN CSX #1 and #2 tracks. 

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Posted by 243129 on Monday, June 17, 2019 7:28 PM

Miningman

Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

 

Poor vetting, poor training, poor supervision.

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Posted by Convicted One on Monday, June 17, 2019 7:22 PM

BaltACD
Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

The way I read the report, the conductor trainee got off the train on the north side, while the conductor got off on the south side. And the CSX train was not occupying the cross over at that time .   While they were inspecting and releasing set handbrakes, the  dispatcher decided the cars needed to be set out on main #2 and the CSX locomotive advanced through the crossover to accomplish this.  But a mechanical dept employee subsequently determined that the cars did NOT need to be set out.

So the train  that was only occupying one main when the conductors began their inspection, had moved to where it was occupying the crossover and both mains...creating a set of circumstances that were new to the conductors since their inspection had begun.

Correct me if I'm wrong, but the CSX train couldn't simply "back up" to where it was again occupying  only main #1, unless one of the conductors was first willing to walk all the way back to the rear end of the train, to "protect" that movement, could it?. 

If this is so,   then it was likely a choice of convenience  by the conductors to use the Amtrak main #3 to walk around the front portion of the CSX train  now stopped on CSX  main #2, as an alternative to  having to walk all the way back to the rear end of their train to allow a backup movement?

At least that is the way it appears to me.

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Posted by Miningman on Monday, June 17, 2019 7:01 PM

Now THAT is the first thing stated here that's makes any sense. Surely this is standard operating procedure. An eight year old can see that.

How on earth could it not be? 

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Posted by 243129 on Monday, June 17, 2019 6:29 PM

BaltACD

 

 
243129
This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

 

Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

 

That being the case they should have contacted the Amtrak dispatcher and requested protection on the adjacent track.

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Posted by BaltACD on Monday, June 17, 2019 6:11 PM

243129
This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

Remember - CSX Rules for inspecting trains for defects identified by Defect Detectors - REQUIRE BOTH sides of the train be inspected.  In which order which side of the train is inspected is not specified by the rules.  I did not notice in the report of this incident, which side the Conductor and Trainee inspected first.  I doubt that being on the 'Amtrak' side of the train indicates that it had been previously inspected.

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Posted by Euclid on Monday, June 17, 2019 5:55 PM

Euclid

What is needed is a new rule:

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group.

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

I am not sure how unusual it is for employees to walk on the track, but in the course of thinking about this new rule, something occurred to me.  I do find it very strange that the two conductors chose to remain walking on that track as a passenger train sped by on the other adjacent track.  Most people would tend to step back off of that track and get further back for more clearance from the moving train.  The two conductors continued walking where they would only be about 13 feet from #66 as it passed by them.  Standing this close to #66 seems much more imprudent than merely walking on the track with no trains approaching.

Not only is standing too close to the path of an approaching train dangerous, but it also is somewhat of a red flag to the train crew who probably think it is unusual and it makes them a bit nervous wondering why a person is standing so close.

Had the two conductors instinctively followed the basic premise of giving #66 a little more room, they would have stepped off the track and into the clear of #175 despite the fact that they were unaware of it coming up behind them. 

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Posted by 243129 on Monday, June 17, 2019 4:43 PM

This from the 'locked' thread:

The CSX train had both CSX main tracks 2 & 1 occupied as they were making a crossover move. Why the conductor and trainee were inspecting the train from a live track when they could have done so from the CSX main #1 side smacks of poor judgement due to inexperience and inadequate training.

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Posted by BaltACD on Sunday, June 16, 2019 7:01 PM

Euclid
What is needed is a new rule: 

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group. 

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

CSX has such a rule for MofW personnel.  Whenever a train passes on an adjacent track they are to stop work and dismount their machines until the train passes.  There is a Employee in Charge as stated in Train Messages that the train much establish contact with to obtain permission to pass through the designated Work Zone and the speed that the train is permitted to operae is also specified by the Employee in Charge.  The Employee in Charge must also know that the members of the MofW Work Zone have placed themselves in a place of safety before issuing the permission for the train to pass through the Work Zone.

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Posted by Euclid on Sunday, June 16, 2019 6:47 PM

What is needed is a new rule:

 

Any time a train passes on a multiple track main line, employees on the ground must stand clear of all tracks of the main line track group.

 

Adhering to this rule would have prevented this Ivy City tragedy and perhaps several hundred similar ones in that past, plus all in the future.  This would surely be one of those rules written in blood. 

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Posted by Euclid on Friday, June 14, 2019 7:05 PM

tree68
 
Euclid
What correction?  What you quoted from me is true.

 

I quoted you, but I added (in bold type) two very important words.

You have no way of knowing what they heard or were thinking.

 

Okay, I see.  Yes I assume they thought they were only hearing the horn of #66.  I also assume they did hear both horns, and that they would have gotten clear had they realized that one of the horns was #66 behind them.  But those are only assumptions because I don't know what they were actually experiencing. 

As for the rule to always expect a train, I think we have no way of knowing whether they were doing that or not.  I do not believe that it logically follows that everyone struck by a train is automatically guilty of not expecting a train.  So I do not assume that they failed to expect a train.  I tried to explain this a little above.        

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Posted by zugmann on Friday, June 14, 2019 5:54 PM

Overmod
Makes me wonder, again, if there is some kind of modern analogue to a Bishop coupling knife that would let you do both opening a knuckle and pushing/pulling a drawbar to alignment conveniently from completely outside the 'engagement zone'

Brakestick for the knuckle.  Drawbars, depends how freely they move.  Some need some might, others you can breathe on them and they slide the whole way over.

It's been fun.  But it isn't much fun anymore.   Signing off for now. 


  

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Posted by tree68 on Friday, June 14, 2019 5:22 PM

Euclid
What correction?  What you quoted from me is true.

I quoted you, but I added (in bold type) two very important words.

You have no way of knowing what they heard or were thinking.

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Posted by Deggesty on Friday, June 14, 2019 4:43 PM

Overmod

 

 
Deggesty

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment

 

 

Johnny, doesn't this belong over in String Lining where we're discussing a different 'attention deficit' bad-judgment accident?

 

Yes, it would fit there.

Johnny

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Posted by Overmod on Friday, June 14, 2019 3:54 PM

Deggesty

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment

Johnny, doesn't this belong over in String Lining where we're discussing a different 'attention deficit' bad-judgment accident?

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Posted by Deggesty on Friday, June 14, 2019 1:24 PM

As to adjusting a drawbar or knuckle while making a joint, I do not recall if there is a rule that says the movement must be stopped before making any such adjustment.

Johnny

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Posted by Flintlock76 on Friday, June 14, 2019 1:11 PM

I remember that rhyme myself, just a appropriate today as it was fifty-plus years ago.

I took it a step further.  If I was riding my bike on a road with a less-than-generous shoulder I rode facing the traffic.

I know you're supposed  to ride with the traffic, but if there was a two-ton mass of machinery coming at me I wanted to know about it!  

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Posted by Euclid on Friday, June 14, 2019 1:06 PM

The rule saying “always expect a train…” means one must know that a train could arrive at any time.  Anybody that works for a railroad knows this fact.  It is a fallacy to conclude that every railroader who is struck by a train did not know this fact.  Of course they knew that trains can arrive at any time.  They just didn’t realize one was arriving when it struck them.  

That realization requires sensory input, which can necessarily be somewhat sporadic and therefore take some time.  If an arriving train happens to be missed by the sensory input.  So is there also a rule requiring employees to always see any danger that exists?  

Also notice that the NTSB report does not say that the victims failed to expect a train.  It says the cause of the accident was their decision to walk on the track.  And yet, they also say there was no prohibition against walking on the track.  The way I see it, the NTSB did not want to prejudice the case by directly finding that CSX caused the accident, but they left the door wide open for that case to be made if anyone chooses to make it.  That is why the cause that they did find seems so nebulous.

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Posted by Miningman on Friday, June 14, 2019 12:35 PM

Single file

Indian style

Facing traffic all the while 

We sang that in grade school .. perhaps politically incorrect these days.

 

 

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Posted by Overmod on Friday, June 14, 2019 12:24 PM

charlie hebdo
Don't walk with the flow because you might not notice a vehicle approaching from behind until it's too late. 

There is a somewhat darker further affirmation of this principle: if you're walking with the flow, you might not notice malicious drivers intent on 'near missing' or actually hitting you, including 'getting you with the door', throwing garbage at you, 'rolling coal' and other pathetic once-probably-more-common-than-they-should-have-been practices.

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