Several good points advanced by all.
I'd just like to add that there is a tendency among us all to promote ourselves to "expert" the longer we work at any given task. Doesn't matter if you're a T&E crew, a boiler mechanic, or an electrician. You get into a routine that you are comfortable with, before long that routine becomes your definitive standard for the "right way things are to be done", and you get to a point where you no longer see any validity in questioning yourself.
That sense of self-assuredness can leave you vulnerable. Human nature, to a large extent.
RE: Disorientation,
A few times at work I have been unlucky enough to find myself between two yard tracks that are both occupied by moving trains (usually one of them is my own train). It is surprising how small the space between tracks is and how little room for error there would be when walking with your head on a swivel.
15 mph seems like 100 when the cars are inches away.
When caught in that situation I will kneel, to avoid becoming disoriented and unbalanced and accidentally stumbling and falling between the moving cars.
The noise problem Balt mentions is very real, when next to a running locomotive one cannot hear much of anything else. Even your portable radio, with the speaker held next to your ear, is very difficult to hear. But the fact is that trains are big, noisy machines, and that is not going to change anytime soon.
A few years ago in Saskatoon, SK a 30-year conductor was struck and killed by a train on an adjacent main track, while he walked back to uncouple the head-end portion of his train. This was in daylight, with the oncoming train displaying blazing headlights and desperately whistling to try and warn him, to no avail. We still don't know why he did not move, even though the outside-facing camera from the oncoming train caught everything.
Greetings from Alberta
-an Articulate Malcontent
EuclidAll that is needed is a training exercise that will subject a person to this direct experience of losing the ability to distinguish between the two sounds of two trains. You can tell people about it all day long, but they will not likely absorb the deep meaning. They will refuse to mentally place themselves into the situation you describe to them. A simple test needs to be set up to show people by direct experience how sinister this odd danger really is. Once they experience that, they will always catch themselves when they are relying on the sense of hearing at times when it may suddenly become incapable of protecting them. There is no need for writing a new rule.
Until you realize that ALL trains can be on you without your hearing them.
In the last 11 years - 4 employees of CSX's Baltimore Division have been killed when being struck by trains that overtook them from behind.
In Philadelphia a Conductor was ridng on the 4th unit of the engine consist when the train was stopped at its crew change point - a following train on an adjacent track struck him in the center ditch between the tracks.
At Doswell, VA a local freight conductor was walking the brake release on his train, North to South, which was on #4 track (which was used as a siding at this location) when he was struck by a passing Southbound operating on the adjacent #3 track - The conductor had been informed that his train, in addition to its brake test, was being held for the Southbound.
And we have the two employees at QN Tower.
In all three of these incidents the employees were 'near' the locomotives of their own train which were idling and thus making a noise , over which it would be difficult to hear any other trains - diesel or electric; and most difficult to hear a electric train.
All these employees knew they were walking along Main Tracks and should expect movements on those tracks in any direction at any time. Each of these employees, except the trainee, had multiple years of real world, real time railroad experience - why they did what they did, we will never know.
I posted the following video from the late 40's in the Factual Video's thread yesterday - being hit by movements has been a issue with railroad operation since the formation of railroads.
https://www.youtube.com/watch?v=BqpayZ2JqlU
Never too old to have a happy childhood!
BaltACD Knowing the last thoughts of the deceased is the only way to intellegently formulate rules and instruction to prevent future individuals from being sucked into the same series of 'trap events' that caused the demise of the original individuals. Today we can only surmise, withoug knowing, what they were actually thinking - whether their brains had even acknowledged the presence of Amtrak 175, let alone whether they had started to take avoiding actions. The human mind responds to many inputs - both internal and external, to be effective in prevention we need to know what inputs had control of the brain(s) in the final seconds and formulate strategys so that 'proper' self preservation thoughts take control of the brain at the earlies possible moment. Writing arbitrary rules is a sure way to have them violated and generally with catastrophic consequences.
Knowing the last thoughts of the deceased is the only way to intellegently formulate rules and instruction to prevent future individuals from being sucked into the same series of 'trap events' that caused the demise of the original individuals.
Today we can only surmise, withoug knowing, what they were actually thinking - whether their brains had even acknowledged the presence of Amtrak 175, let alone whether they had started to take avoiding actions. The human mind responds to many inputs - both internal and external, to be effective in prevention we need to know what inputs had control of the brain(s) in the final seconds and formulate strategys so that 'proper' self preservation thoughts take control of the brain at the earlies possible moment.
Writing arbitrary rules is a sure way to have them violated and generally with catastrophic consequences.
I assume their final thoughts were of great shock, surprise, and regret. I also assume that they were not aware of #175 coming up from behind them until either after the train struck them or just a second or two before it struck them. And I assume that they would not have been killed or injured had it not been for the unusual synchronicity of two Amtrak trains converging on them at precisely the same moment. If #66 was not approaching, they would have most assuredly heard #175 coming up behind them.
What we can learn is to understand the highly unique danger of this unusual type of accident. What protects people from it is far less dependent on how careful they are, but mainly dependent on the rarity of the necessary coincidence of two trains converging on a person simultaneously.
The essence of the Rule 10, which applies to this case, is that an employee must be alert for approaching trains at any time, in either direction, on any track.
What is lacking is that the employee must also be alert to a loss of alertness for trains. That is the killer. Being alert to approaching trains requires the sense of sight or hearing. Hearing works full time, while sight varies according to its direction. Sight cannot be in every direction at the same time. So, a fully alert person needs both sight and hearing. Hearing fills in the gaps in sight as sight confines itself to only one direction at a time.
When a train does approach, it tends to fulfill the expectation of an alert person expecting a train. It sort of closes that loop, so to speak. At that moment, a person tends to lower their wariness because they have been expecting train, and now they perceive it to be arriving. Therefore, with lowered wariness, it becomes easier of overlook the existence of a second train approaching.
Then also, at that critical moment of reduced wariness, the person loses the ability of their hearing to distinguish source and direction of sound because sounds of both trains combine and are perceived as the sound of just one train.
To further compound the problem, the approach of the one train that the person sees draws the person’s attention to it, thus making them less likely to look in other directions for other trains. They were expecting a train and that one train has arrived. It is unusual for a second train to arrive at exactly the same time, and they do not expect that even though the rule requires that. The vision of their eyesight binds their attention to that approaching train they see.
This is the death trap that is sprung every time two trains converge on a person. This sudden loss of the ability for hearing to distinguish sound direction and source happens without notice to even the most otherwise alert person. So it leaves a person defenseless without realizing it. The only thing that saves people is the rarity of the two-train coincidence. In that circumstance, the “be alert” rule is almost irrelevant.
Therefore, part of the solution to the problem is to rewrite rules to keep people off of live track with protection assuring that no train will approach them.
But the other part is that we can better understand this odd event of distraction that can occur as a sort of perfect storm of two trains converging on a person who thinks he/she is perceiving just one train.
The mechanics of this unique distraction hazard are very clear and predictable. It does not require deep analysis of a person’s thought process in order to develop some type of self-preservation defense.
All that is needed is a training exercise that will subject a person to this direct experience of losing the ability to distinguish between the two sounds of two trains. You can tell people about it all day long, but they will not likely absorb the deep meaning. They will refuse to mentally place themselves into the situation you describe to them. A simple test needs to be set up to show people by direct experience how sinister this odd danger really is. Once they experience that, they will always catch themselves when they are relying on the sense of hearing at times when it may suddenly become incapable of protecting them. There is no need for writing a new rule.
BaltACD The only way we can 'learn' more about this incident is from technology that has not been invented 'yet' - downloading the last thoughts of the deceased so they can be read and 'understood' by those that continue to live.
The only way we can 'learn' more about this incident is from technology that has not been invented 'yet' - downloading the last thoughts of the deceased so they can be read and 'understood' by those that continue to live.
Knowing the last thoughts of the deceased is not necessary to preventing this from happening again. There is plenty that can be learned from this accident. And it should not have required this accident to learn what needed to be known. If any thought process needs to be examined, it is that of the NTSB.
In referring to whether or not the two conductors were prohibited from walking on the Amtrak track in the manner they did; I am stating the thought process of the NTSB as they detail in their accident report. Here is their thought process as extracted from their report. The following four statements are in sequential order and context, but broken out to make them clearer:
“The operating crews were not prohibited from walking either on or near the Amtrak tracks.”
“The NTSB believes that the crew should have been prohibited from walking near the live tracks of the other railroad.”
“However, there are circumstances when the operating employees cannot safely walk away from the other railroad’s tracks. In these situations, when the crew is fouling the other railroad’s adjacent track, they would need protection.”
“A current process is readily available to provide this protection. For example, a train dispatcher will communicate with another train dispatcher from a different railroad if a derailed train has obstructed an adjacent railroad’s track.”
Regarding whether or not the two conductors were prohibited from walking on the Amtrak track, Essentially, I interpret the above four NTSB statements as follows:
Were not prohibited.
Should have been prohibited.
Were prohibited.
Train crews are NOT exempt from the FRA on-track safety rules. (all inclusive and obviously nobody was acting as a lookout here - situational awareness failure, they fouled a track they did not control or have access to control - technically they were unqualified trespassers on another railroad and obviously they also fouled the other railroad's track to boot. Not Good. They were "working" where they should not have been.) The excuse that they were over where the walking was easier doesn't fly.
Here in Denver, RTD (light rail) is having issues with UP and BNSF employees fouling their main track causing several near miss incidents.
Truly sad chain of events compounded by a 214 OTS violation.
(*) Out west on UP or BNSF and you are working on track machinery or on foot less than 24 feet (company rule exceeds FRA) from an adjoining live controlled track, you must be off the machinery and in the clear when another train or work equipment passes by on that controlled track. All work stops until the passing train or equipment is by you and you can see it's clear. (Speed/ Vision Distance rule applies)
EuclidI also find it odd that the NTSB would find the probable cause of this accident to be the two conductors deciding to walk on the Amtrak track, while telling us that the employees were entirely permitted to walk there.
Just because you can, doesn't mean you should...
A cardinal rule of being near railroad tracks is always expect a train.
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...
Some questions are raised by the CSX accident at Ivy City, D.C. in which a conductor and student conductor were struck and killed by an Amtrak train.
In other discussion of this topic, some have expressed certainty that death of the two conductors was due to their negligence in deciding to walk on an Amtrak track as they returned to their locomotive. They were struck and killed by an Amtrak train approaching them from behind at the same moment that another Amtrak train was approaching on the other Amtrak track from ahead of them. So an obvious conclusion is that they were not paying enough attention, were not expecting trains on any track, any time, etc. And yet once a person decides a track is clear to cross, they have correctly ceased expecting a train. So the rule is somewhat of a platitude.
It is clear that had they not been fouling the Amtrak track, they would not have been struck. Yet their job on CSX required them to inspect a CSX freight train which meant walking along much of that train. I am not sure of which side it was necessary to walk in this particular case, but the point is that it could have been either or both sides. So my question goes to the larger premise of how it can be considered safe to inspect a train in such close proximity to the Amtrak line even if the inspecting personnel are not actually fouling Amtrak. Or more precisely, how do you work in such close proximity to the foul zone of a track without inadvertently entering it?
In their accident report, the NTSB says the following:
There is not any prohibition against employees walking on a live track.
There is not any system by which CSX could request that Amtrak provide protection for CSX employees working in dangerous proximity to Amtrak track.
NTSB wishes there was such a system and recommends that it be set up by both companies.
The cause of the accident was the decision of the two conductors to walk in the fouling zone of the Amtrak track.
The CSX train was on one CSX main with the hind end cars, and the other main with the head end cars. It was also occupying a crossover between the two mains. Focusing on the head end portion of the CSX train since that portion was along the track on which the conductors were struck:
On one side of the standing CSX train (head end), there was a CSX mainline track; and on the other side was an Amtrak mainline track. If there were a train on the Amtrak track, its side would be about 5 feet from the side of the CSX train. So that is a 5-foot wide space for a person to stand in. This is the space that would be safe for a conductor to be in while inspecting the train.
Inside of the 5-foot space, one side is defined by the presence of the stopped train being inspected. The other side is defined by the start of the fouling zone for the Amtrak track. At the threshold of this fouling zone, a person would want to allow a little more space because it would be unsafe to use up all of the space right up to the point where you contact a moving train. So how much of the 5-foot zone of clearance can you use when inspecting a train? Specifically, how close can a person safely be from the fouling boundary of a fast passenger train? Bear in mind that air movement and spatial disorientation can also be induced by a fast train at close proximity.
It is my understanding that Amtrak trains on this stretch of track are allowed to travel at speeds up to 125 mph. So in terms of safe railroad practice, how close can a worker be to a 125 mph passenger train? What do the rules say about this? Where is the line drawn? If you clear the train by one inch, it is not going to hit you. But how can a person be expected to work safely even within a couple feet of contacting a 125 mph passenger train? At the site where the conductors were killed, such a train could not have been seen until it was only about 8 seconds away from them.
In my opinion, I would consider anywhere in that 5-foot clearance zone to be unsafe unless there was formal train protection provided to assure that no trains would pass on the empty Amtrak track.
Yet, because CSX and Amtrak are two different companies, there is no system by which CSX can arrange protection from Amtrak trains. The two conductors killed in this accident did not have the option of protection. Whether their job required them to be in the fatal location in this specific case, I don’t know. But it certainly could have required that, and no doubt would require that in the future, and has probably required it in the past. And yet CSX has no means of protecting employees from this extremely dangerous need to be working in or near the fatal foul zone. I find it incredibly odd that CSX, like most railroads, has an ultra-high sensitivity to safety hazards and safe practices to address them. But then they have no concern about the danger of sending train crewmen into the death trap of working on the ground, in confined spaces, with 125 mph trains passing within a couple feet of them, and only a few seconds of warning.
I also find it odd that the NTSB would find the probable cause of this accident to be the two conductors deciding to walk on the Amtrak track, while telling us that the employees were entirely permitted to walk there.
https://www.ntsb.gov/investigations/AccidentReports/Reports/RAB1901.pdf
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